EM Coding Alert

Question: I have a rather involved claim that I need help with. A 22 year-old established patient comes to the office with a nosebleed that she has not been able to control on her own. She reports that she was hit in the face with a soccer ball. There is no significant past medical history in her record around issues involving nosebleeds or bleeding disorders. After performing an expanded problem-focused history and exam looking for signs of face trauma outside of the nosebleed, the physician determines that the nosebleed needs further treatment. He performs another exam to find a bleeding diathesis; oozing of blood is noted from the right inferior nasal turbinate during this exam. The physician places a compressed nasal sponge in the affected nare, expanding it with a few drops of oxymetazoline. This controls the bleeding. Is this an E/M service or a procedure?

Minnesota Subscriber

Answer: It’s certainly a procedure, and you should be able to code an E/M as well since the physician checked the patient for signs of facial trauma and then treated the nosebleed.

On the claim, report:

• 30901 (Control of nasal hemorrhage, anterior, simple, [limited cautery and/or packing] any method) for the nosebleed repair.
• 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; and medical decision making of low complexity) for the E/M
• 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) appended to 99213 to show that the E/M was separate from the nosebleed treatment.
• R04.0 (Epistaxis) appended to 30901 and 99213 to represent the patient’s nosebleed.

Remember: To make this claim solid, make certain the documentation clearly indicates all services performed and the decision-making logic. Then, include the procedure note showing that the bleed was stopped with packing or cautery, along with a note supporting the E/M that preceded the nosebleed treatment.