ED Coding and Reimbursement Alert

Test your coding knowledge.  Determine how you would code this situation before looking at the box below for the answer.
Question: We recently saw a patient twice in one day because of repeated severe nosebleeds, which were the result of drug use. The 24-year-old male came in at 4 p.m. and cautery was performed. He returned at 8 p.m. with another nosebleed that was also cauterized. What codes can we assign a visit code and nasal hemorrhage code? Can both of the visits be billed?

Illinois Subscriber

Answer: In many instances, both an ED visit code and the cautery code should be billed for the first encounter, while only the cautery code would be reported for the second.
 
When the patient initially presents to the ED, the physician will most likely conduct an E/M service to determine the cause of the nosebleed trauma, for instance, in which case an x-ray may be performed. In other instances, blood tests may be ordered to establish if a bleeding disorder may be present. If this type of separately identifiable E/M service is being provided, a code from the 99281-99285 series may be used, appended with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). If no E/M service is provided and documented, of course, the code should not be assigned. In addition, the cautery code or codes from the 30901-30906 series are also assigned (e.g., 30903*, control nasal hemorrhage, anterior, complex [extensive cautery and/or packing] any method).
 
Because the cause of the nosebleed was determined at the first visit, it is unlikely an additional E/M service would be provided at the second. Only the cautery code would be reported. If the same procedure were provided both times, the cauterization would be modified with -76 (repeat procedure by same physician) or -77 (repeat procedure by another physician). On some occasions, however, a different code might be used for the second visit. Perhaps the first nosebleed was treated with simple packing (30901*, control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method), while the second required more extensive treatment as described in 30903*. The diagnosis code would be 784.7 (epistaxis). Alternatively, depending on the nature of the nosebleed, 30905 (control nasal hemorrhage, posterior, with posterior nasal packs and/or cauterization, any method; initial) may be reported for the first visit and 30906 (subsequent) for the second.
 
ED physicians and coders should recognize that there is no guarantee that both cauterizations will be paid, however. Chart notes should clearly describe the circumstances and emphasize that the patient's condition was not resolved and a second treatment was therefore medically necessary.