Primary Care Coding Alert

Question: An established patient reports to the FP with a nosebleed that he could not stop on his own. The FP applies a nitrogen stick to the bleeding site. Should I report an office visit code for the bleeding control?

Massachusetts Subscriber

Answer: Because the FP used cauterization to control the bleeding, report 30901 (Control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method), which pays more (2.64 relative value units) than all established patient office visits except 99215 (3.43 RVUs). But if the physician used only pressure to control the nosebleed, and no kind of cauterization, you would code only the office visit. Link the nosebleed control to epistaxis (784.7).

If the FP performs a significant and separate E/M service from the minor evaluation that is otherwise part of 30901, such as evaluating associated head trauma, you may also report the office visit (99201-99215) appended with modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service).

On claims containing an E/M-25 service and 30901, you may want to also report 99058 (Service[s] provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service). Code 99058 is appropriate if the triage nurse considered the patient an emergency that required disrupting the physician's scheduled appointments.