Primary Care Coding Alert

You Be the Coder:

Complex or Simple Nosebleed Treatment?

Question: An established patient reports to the FP with a bleeding left nostril. She tells the FP that it started about three hours ago, and she could not stop it on her own. After a level-two E/M, the FP cauterizes the nostril with a silver nitrate stick and then packs the nostril extensively to soak up the blood. Should I code this as a simple or complex procedure?

Missouri Subscriber

Answer: Since the FP needed to use cautery and extensive nasal packing, you-ll be able to report the service with 30903 (Control nasal hemorrhage, anterior, complex [extensive cautery and/or packing] any method). So on the claim, report the following:

- 30903 for the nosebleed treatment

- 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem focused history; a problem focused examination; straightforward medical decision making) for the E/M

- modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) attached to 99212 to show that the E/M was separate from the nosebleed treatment

- 784.7 (Epistaxis) attached to 30903 and 99212 to prove medical necessity for both services.

Be sure to include a description of the cautery and packing in the documentation. This will alert the payer that you took the extra steps to justify reporting 30903.

On a 30903 claim, a payer is likely to want to see:

- indications for the procedure

- techniques used to stop bleeding

- patient response to bleeding prevention techniques

- name of the medical professional who performed the treatment.

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