ED Coding and Reimbursement Alert

Check the chart carefully to see if a separate procedure is warranted for nose bleed presentations.

Many patients present to the ED complaining of a nosebleed, but not all of them should be billed for treatment of epistaxis.

Some patients present due to epistaxis but are not actively bleeding in the ED. In these encounters the physician may not perform a billable procedure, so you would report only the E/M to identify the services the physician provides, explains Todd Thomas, CPC, CCS-P, President of ERcoder, Inc., in Edmond, OK.

Even some presentations with minor active bleeding may not support reporting a procedure code for treatment when the physician directs the patient in self-administered home remedies such as patient applied ice, or direct pressure. Any physician treatment of an active nosebleed is likely going to support the assignment of a nosebleed treatment CPT® code, Thomas adds.

Choice of Method Marks Most 30901 Claims

Several factors can qualify the nosebleed fix to the level of procedure, according to Thomas. You might be able to report 30901 (Control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method) if the notes indicate that the ED physician performed chemical cautery with a silver nitrate stick, brief electro-cautery, or packed the nose with pledgets or a limited amount of gauze p to treat a nosebleed, Thomas explains.

Technique and Complexity May Warrant 30903

Train ED physicians to accurately document their treatment methods and make sure ED coders know how to recognize the methods that support reporting 30903 (Control nasal hemorrhage, anterior, complex [extensive cautery and/or packing] any method).There are several scenarios that would indicate complex treatment.

You should consider 30903 when the physician makes multiple attempts at "simple" treatments to stop the bleeding. Also, the physician might use "more aggressive treatment" on complex nosebleed treatments, Thomas says. These methods may include traditional nasal packing (gauze), a prefabricated nasal sponge, or an epistaxis balloon.

Consider these clinical scenarios from Thomas:

Example 1: A 15-year-old reports to the ED with a nosebleed that started about 30 minutes ago from being hit in the face with a soccer ball during a game. He is bleeding from both nares. The physician cleans off the blood and examines the nares, finding several small areas of bleeding from the internal mucosa but no fractures. He orders an x-ray for confirmation. He places nasal tampons before the x-ray, then has to replace them when the patient returns to the ED. Before the patient achieves satisfactory hemostasis, the ED physician replaces the tampon, ultimately packing the entire nasal vestibule. Once bleeding stops, the physician gives the patient detailed discharge instructions and sends him home.

Example 2: Consider an epistaxis encounter where the physician performed bilateral anterior packings and on the right side posterior packing. How would you report the procedures since they are not identical bilaterally?

Anterior packing is included in the posterior packing, so you cannot bill 30903 and 30905 together on the same side. For this scenario, report 30903-LT (Control nasal hemorrhage, anterior, complex [extensive cautery and/or packing] any method, Left side) on the side with anterior packing only, and 30905-RT (Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial, Right side). While some payers may request the LT/RT designation others may require Modifier 59 (Distinct procedural service) to represent that two separate and distinct anatomical areas were treated, says Thomas.