Primary Care Coding Alert

And remember these 3 proven tips for billing success.

If a patient presents to your provider seeking treatment for nosebleeds, do you know which procedure code to use to accurately represent the service? Is a procedure code even the right way to go about reporting your provider’s management of the patient’s condition?

If you’re not sure of the answers to these questions, maybe it’s time to take a crash course in nosebleed coding using these scenarios to guide you.

Scenario 1: Use E/M for Simple Control

An established patient presents with mild bleeding in the left nostril. The physician performs a history and exam, then applies direct pressure to the affected nostril before applying a cotton swab into the nostril. The provider then removes the swab after a few minutes, examines the patient’s left nostril a second time, and notes the bleeding has stopped.

In this scenario, even though the provider packed the patient’s nostril, you won’t be able to use 30901 (Control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method) because “there was no cautery performed or packing left in place to remain after the encounter,” per CPT^® Assistant (Volume 30, Number 7, 2020).

Instead, “If simple procedures like ice and pressure succeed by themselves, an appropriate evaluation and management (E/M) service is appropriate,” says Chip Hart, director of PCC’s Pediatric Solutions Consulting Group in Vermont and author of the blog “Confessions of a Pediatric Practice Consultant.” In this case, as your provider is treating a single, self-limited, or minor problem, and there is a low risk of morbidity from the treatment, that would be 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making …) for a patient established to your practice.

Scenario 2: Use 30901 and E/M-25 for Cauterization

An established patient reports that his right nostril started bleeding two hours ago and that putting pressure against the nostril failed to stop it. The physician takes an appropriate history, examines the patient, and discovers persistent ooze from the septum during a check of the right nostril. The patient is otherwise healthy and has no other bleeding.

The practitioner places cotton strips soaked in Pontocaine and epinephrine in the patient’s right nostril for 15 minutes. After the physician removes the strips, bleeding still occurs from the same nostril, which the physician cauterizes with a silver nitrate stick.

This is an example of a simple anterior treatment for which you will report 30901. You can also code the E/M in this case as “the clinician has discerned the cause of the bleed is something like a ruptured blood vessel, which is easily a clinical assessment. In this case, proper coding might include both the E/M and 30901,” Hart notes. This time, though, given the condition has risen to the acute, uncomplicated level and there is a risk, albeit low, involved in the treatment, you’ll be able to justify a higher level of service such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making …).

And remember: as the E/M is significant and separate from the cauterization service, you’ll append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to 99213.

Scenario 3: Use 30903 for Complex Bleeds/Multiple Methods

An established patient reports significant bleeding from the right nostril after being hit in the nose. During an exam, your provider notes significant bleeding from the middle and inferior turbinates and the nostril floor. The provider places an expandable cellulose nasal pledget that has been soaked in antibiotic ointment and oxymetazoline into the anterior of the patient’s nose.

This time, your E/M coding will probably remain the same, and you’ll still go ahead and bill 99213-25. But the procedure your provider performed is more complex than the previous scenarios, so you can report 30903 (Control nasal hemorrhage, anterior, complex [extensive cautery and/or packing] any method) for the nosebleed treatment.

And Don’t Forget These 3 Things for Complete Coding

1) Nosebleed treatment codes are unilateral. Codes 30901 and 30903 represent treatment on one nostril. If your physician performs nosebleed treatment on both nostrils, you should report 30901 or 30903 with modifier 50 (Bilateral procedure) attached. Alternatively, you can use modifier XS (Separate structure …) or 59 (Distinct procedural service), depending on payer preference for separate-side bleed control.

For example, if your provider performs simple anterior cautery on a patient’s right nostril and anterior complex packing on the left side, depending on payer preference, you would submit 30903, 30901-59 or XS. These modifiers tell the insurer that the complex hemorrhage control occurred on a different side from the simple cautery. If the payer processes the modifiers for laterality, instead of modifier 59, you can use the appropriate LT (Left side …) and RT (Right side …) modifiers (such as 30903-LT and 30901-RT).

2) Simple or complex? Let the provider decide. “CPT^® does not define ‘simple’ or ‘complex’ in this context. Instead, code choice code is at the discretion of the physician’s and is based on the level of difficulty involved in the procedure,’” according to Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

3) Add this dx for medical necessity. Whether you choose an E/M on its own, or 30901 or 30903 with an E/M, you’ll still need to show your payer that the service was medically necessary. In any of these cases, you’ll use R04.0 (Epistaxis).