Primary Care Coding Alert

Question: We recently saw a patient who came to the practice with a nosebleed. One of our physicians stopped the bleed, but we’re not sure if we should code this as an evaluation and management (E/M) visit or bill for a procedure. What is the best way to document this scenario?

North Carolina Subscriber

Answer: How you code this scenario is completely dependent on what your provider did to stop the nosebleed.

You’ll usually code simple efforts, such as applying pressure or ice to the nose, as an E/M service, most likely 99201 (Office or other outpatient visit for the evaluation and management of a new patient …) if the patient is new or 99212 (Office or other outpatient visit for the evaluation and management of an established patient …) if the patient is established.

But if your provider used a chemical cautery, such as a silver nitrate stick, or a nasal spray to shrink or anesthetize the nasal area, or if the provider packed the patient’s nose, you could then code the encounter with a procedure code such as 30901 (Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method).

Importantly, the CPT^® descriptor for 30901 contains the words “any method.” If your provider made a clinical assessment regarding the cause of the nosebleed — that it was caused by a ruptured blood vessel, for example — and there were no diagnostics used to verify this, then you could code both the E/M and 30901 with 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) attached to the E/M.

Modifier alert: In addition to using modifier 25 on the E/M service if needed, you will need to append a laterality modifier to 30901. Because the code does not specify which nostril, or nostrils, the provider has treated, you will have to specify whether the procedure was on the right (modifier RT), the left (modifier LT), or if it was performed bilaterally (modifier 50).

Coding alert: There are three other nasal hemorrhage control procedure codes that look similar to 30901: 30903 (Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method), 30905 (Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial), and 30906 (… subsequent). Because of their complexity, they are more applicable to the emergency department (ED) setting or to an otolaryngologist’s services, and it is less likely that you would use them in a primary care setting.