Primary Care Coding Alert

When a patient reports to the FP for anterior nosebleed treatment, the coder chooses an E/M code, a procedure code ... or both.

The code, or codes, you choose for each nosebleed repair depends on encounter  specifics. Check out these nosebleed fix case studies, which explain the three most likely coding scenarios FP practices will see.

If a patient reports to the physician with a nosebleed and the physician stops the bleeding with standard methods, you should choose an E/M code for the entire encounter, confirms Jeffrey Linzer Sr., MD, FAAP, FACEP, Associate Medical Director for Compliance, Emergency Pediatric Group, Children's Healthcare of Atlanta at Egleston.

This means you have to be on guard for nosebleed treatments that don't qualify as nosebleed repairs, for coding purposes. Standard nosebleed-stoppage methods include ice, pressure, or gauze. When the provider stops a nosebleed in this manner, "no billable procedure was performed," Linzer relays.

Example: A mother brings her 8-year-old son into the office; both are established patients. The boy reports that his nose has been bleeding "off and on" all morning. The nonphysician practitioner (NPP) in the FP's practice applies a combination of gauze and ice, and the bleeding stops. Notes indicate a problem-focused history and exam.

On the claim, you'd report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making ...) for the nosebleed treatment with 784.7 (Epistaxis) appended to represent the patient's nosebleed.

Explanation: Even though the NPP stopped a nosebleed in this instance, the treatment methods do not elevate the service to procedure level, for coding purposes.

You'll come across other encounters in which the physician's nosebleed cessation efforts will merit procedure status; when this occurs in the FP office you'll most often report 30901 (Control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method), says Linzer.

The methods that the FP would most likely use during a 30901 encounter are cautery and packing, Linzer says.

Good advice: When scanning the procedure note, be on the lookout for these terms, which could indicate a 30901 service, offers Linda Martien, CPC, CPC-H, CPC-I, secretary for the American Academy of Professional Coders' (AAPC) national advisory board:

• hemostasis (control of bleeding)

• bovie

• silver nitrate

• electrocautery

• chemical cauterization.

While presence of these terms in the encounter notes might mean the physician provided a 30901 service, you should check all the encounter specifics before deciding if that's the case.

Example: An established patient reports to the FP for a scheduled appointment to treat a nosebleed that he has not been able to stop after a sneezing fit about five hours earlier. The patient's right anterior nasal tissues are dry and scaly; there also appears to be bleeding in the anteriolateral aspect of the right sinus passage.

Initial attempts to stop the bleeding include applying pressure across the bridge of the nose, ice, and seating the patient upright with his head tilted back.

These actions slow the bleeding to an ooze, at which point the FP uses a silver nitrate stick to cauterize the source of bleeding. After several minutes, the bleeding stops, and the FP sends the patient home.

In this example, you should report 30901 for the FP's treatment with 784.7 appended. Your payer may want to see modifier RT (Right side) to indicate specific repair location. Check with a rep if you are unsure about a payer's modifier RT/LT (Left side) policy.

Addendum: If the physician happens to perform simple anterior nosebleed repair on both of a patient's nostrils, report 30901 with modifier 50 (Bilateral procedure) appended. FP coders should also be aware of the 30903 (... complex [extensive cautery and/orpacking] any method) code, but they should not count on using it often.

The basics: Complex repair is a surgical procedure typically performed in hospitals; the FP will rarely treat a patient who needs this type of care. "I don't believe that many FPs would perform complex hemorrhage control," Linzer says.

In any case, you should tread carefully when considering using the 30903 code for your FP's nosebleed repair services.

The Case 2 example did not address an E/M service that could occur prior to an FP's nosebleed repair service.

Best bet: Be sure to check each 30901 encounter for evidence of a separately identifiable E/M. Consider thisexample from Linzer:

A 42-year-old new male patient comes to the office with a nosebleed that he has not been able to control at home. After performing an expanded problem focused history and exam to search for signs of a bleeding diathesis, the FP finds only oozing blood from the right inferior nasal turbinate. The FP places a compressed nasal sponge in the affected nare, expanding it with a few drops of oxymetazoline. This attempt controls the bleeding.

Notes indicate straightforward medical decision making.

On this claim, you should report the following:

• 30901 for the nosebleed repair

• 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making ... ) for the E/M service

• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service)  ppended to 99202 to show that the E/M and repair were separate services.

• 784.7 appended to 30901 and 99202 to represent the patient's nosebleed.

Remember: On all E/M plus 30901 claims, you should include "a procedure note, separate from an E/M documentation, showing that the bleed was stopped with packing or cautery, " advises Linzer.