EM Coding Alert

Question: Our provider just saw an established patient with a nosebleed. The patient’s mother explained that the bleed started the day before, and that they had managed to stop it temporarily using compression. As the bleed returned later, the mother decided to bring the child in, and after an examination of the child’s nose, our provider found a small pebble lodged in the child’s left nostril. After removing the pebble with forceps, our pediatrician then packed the child’s nostril with gauze, which stopped the bleeding.

Should we report this as just an E/M visit, or should we document this another way?

Washington Subscriber

Answer: The fact that your provider did more than simply stop the nosebleed with ice or compression indicates that this service went beyond a simple E/M visit, though you should certainly code for one because the provider examined the patient and found the epistaxis, or acute nasal hemorrhage, which is a clinical assessment.

For that, you should easily be able to justify 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity). And as you will want to document the additional work involved in removing the pebble, you will need to append 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) to the E/M.

Choosing a code for the for the foreign body removal (FBR) of the pebble is also fairly straightforward. For that, you would use 30300 (Removal foreign body, intranasal; office type procedure). But as the code does not designate from which nostril the removal takes place, your payer may require you to add modifier LT (Left side) to add specificity to your documentation.

Your choice of a code for stopping the bleed is a little trickier, however, as you have two to choose from: 30901 (Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method) and 30903 (Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method). In this situation, however, 30901 best describes your provider’s work as there really is nothing complex about the procedure.

Lastly, you will need to select diagnosis codes to go with the E/M and procedure codes. You’ll pair the 30901 and 99213-25 with R04.0 (Epistaxis), while T17.1XXA (Foreign body in nostril, initial encounter) will pair with the 30300 and 99213-25.