Primary Care Coding Alert

Question: How can I report epistaxis treatment when the provider didn’t perform cauterization or packing?

Maine Subscriber

Answer: If the provider did not perform cauterization or packing, then you cannot report common epistaxis codes such as 30901 (Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method), 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), or 30906 (Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; subsequent). However, that doesn’t mean you can’t report the encounter. You’ll simply report an evaluation and management (E/M) service.

For example, let’s say an established patient presents with mild anterior bleeding in the left nostril. The physician performs a history and exam, then applies ice and 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 situations such as this, where some ice and a little pressure are enough to stop the bleeding, you can report an E/M service. 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.

Remember: No matter which service code you report, you still need to show your payer that the service was medically necessary. In any of these cases, you’ll use R04.0 (Epistaxis).