Primary Care Coding Alert

Plus: Remember right/left modifiers according to payer policy.

Under ICD-9 rules, you have just one code to report for nosebleeds, whether a patient comes to your office with active bleeding or has nosebleeds so frequently he wants to learn whether something more complex might be happening to cause the problem. Your go-to diagnosis is 784.7 (Epistaxis), which describes all nosebleeds that aren't caused by a more complex condition.

ICD-10 changes: When the ICD-10 transition takes place, you'll benefit from a one-to-one crosswalk. Code R04.0 will be your new diagnosis code when reporting nosebleeds.

Documentation: Physicians should continue to document nosebleed cases as they have been. Details regarding the timing, duration, severity, context, modifying factors, and other pertinent information help ensure a complete note.

Keep in mind that some insurers want to know which nostril was bleeding via modifiers such as RT (Right side), LT (Left side), or 50 (Bilateral) applied to the CPT® code that represents treatment of the nosebleed (e.g. 30901, Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method). Therefore, provider documentation should very clearly include this information. In addition, if another cause is discovered for the bloody nose (such as a nasal fracture), you would report the fracture diagnosis code instead of the epistaxis.

Coding tips: When the ICD-10 transition gets close, be sure to replace 784.7 on your superbills with code with R04.0.