You-ll need detailed notes from the physician to justify a complex repair code When a patient presents to your ED with a nosebleed, you-ll have to pinpoint the extent of the treatment before deciding on the proper code. The answers you seek should show up in the op notes for the encounter, and your ED physician should be very specific about his actions and the methods he used to stop the bleeding.
Consider Reporting a Low-Level E/M While CPT has several codes to describe different types of nosebleed treatment, you-ll have to meet certain criteria to use them. And you won't report all nosebleed treatments with procedure codes--sometimes, an E/M services is all you should report, says Joan Gilhooly, CPC, CHCC, president of Medical Business Resources LLC, in Deer Park, Ill.
When? If the physician succeeds in stopping the nosebleed with conventional methods, such as ice or pressure, the service will likely only qualify as an E/M, Gilhooly says.
-The physician has to go past the normal means of stopping a nosebleed- to use the procedure codes, she says. Mull Over 30901 for Nitrate Stick Use If the physician must use more complicated means to stop the bleed, he may be performing a simple anterior repair, which you would report with 30901 (Control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method), says Elijah Berg, MD, FACEP, vice president of MRSI, an ED coding and billing company in Stoneham, Mass.
-You would report 30901 when there has been minimal cautery performed or something less than the entire anterior nasal vestibule has been packed. This might involve a few dabs with a silver nitrate stick or use of some small pledgets,- Berg says.
Example: A 25-year-old female presents to the ED with a moderate nosebleed. Upon interviewing her, the physician finds that the patient has had them before, but this one has lasted for 45 minutes. The physician identifies a small area of bleeding and performs limited cautery with a silver nitrate stick to stop the bleeding.
On the claim, you should:
- report 30901 for the nosebleed repair.
- attach 784.7 (Epistaxis) to 30901 to prove medical necessity for the repair. When you are reporting nosebleed fixes in the ED, Gilhooly says, you should include a detailed procedure note on the claim.
-One of the deficits I see sometimes is that the physician just says -controlled nosebleed- in the report. You need to have a separate procedure note because there are many things that could cause the nosebleed,- she says.
