Revenue Cycle Insider

Know when you should, and should not, code for laterality.

When your otolaryngologist performs nosebleed control, your coding can take a number of different routes depending on the severity of the condition and complexity of the service. Simplifying the epistaxis control coding process is easy, however, if you ask these five very simple questions.

1. Ask, “Is This an E/M or Something More?”

Not all epistaxis encounters require a nosebleed control code. Some can be documented with a simple evaluation and management (E/M) code, depending on what the provider does to stop the bleed.

Consider this scenario: An established patient presents with mild bleeding in the left nostril. The otolaryngologist performs a history and exam, determines it’s an anterior bleed, then applies direct pressure to the affected nostril before applying a cotton swab into the nostril. After a few minutes, the provider removes the swab, examines the patient’s left nostril a second time, and notes the bleeding has stopped.

In this scenario, even though the provider packed the patient’s nostril, you won’t be able to use a nosebleed control code because “there was no cautery performed or packing left in place to remain after the encounter,” per CPT^® Assistant (Volume 30, Number 7, 2020). Instead, as the provider is treating a single, self-limited, or minor problem and there is a low risk of morbidity from the treatment, you would probably report 99212 (Office or other outpatient visit for the evaluation and management of an established patient … straightforward medical decision making …) for an established patient.

2. Ask, “Where Is the Nosebleed Located?”

Epistaxis control is represented by several CPT^® codes, and knowing which to choose and in which circumstance is crucial to coding the encounter. When your otolaryngologist treats an anterior nosebleed — one that originates toward the front of the nose in the frontal, maxillary, or anterior ethmoid sinuses — you should report either 30901 (Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method) or 30903 (… complex (extensive cautery and/or packing) any method).

CPT^® designates a separate code set for treating nosebleeds that occur in the back, or posterior, of the nose in either the posterior ethmoid or sphenoid sinuses: 30905 (Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial) and 30906 (… subsequent). You would use 30906 if the otolaryngologist is treating the patient again after treatment during an initial visit for the same condition.

Coding alert: Because National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) edits bundle 30901 and 30903 into 30905, you should submit only one same-side hemorrhage-control code for each encounter. So, if your provider treats both anterior and posterior bleeds, report only 30905. However, the edits carry a modifier indicator of “1,” meaning that you can override the edit with an NCCI-associated modifier when circumstances and documentation support it.

3. Ask, “Is This a Simple or Complex Cauterization?”

The codes for controlling anterior nosebleeds are separated into simple (30901) or complex (30903). However, CPT^® does not define what constitutes either level of complexity. Essentially, simple procedures may include ice and pressure, whereas complex procedures will occur deeper into the nose and may involve multiple applications of the coagulation method, or additional layers of packing.

Whether the cauterization procedure is simple or complex is based on the level of difficulty involved in the procedure and is up to the provider’s judgment. In other words, the choice to code either 30901 or 30903 is at the discretion of the physician.

4. Ask, “Was an Endoscope Used in the Epistaxis?”

If the epistaxis control involves endoscopy to locate the source of the hemorrhage, it’s not a good idea to code 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) along with an epistaxis control code because this is also subject to another group of NCCI PTP edit pairs, which bundle epistaxis codes 30901-30905 into diagnostic nasal endoscopy code 31231. However, like the edits bundling 30901 and 30903 into 30905, the edit also carries a modifier indicator of “1,” so the edit can be unbundled with an NCCI-associated modifier when appropriate. Interestingly, 30906 is not subject to such an edit.

Also, if surgery is necessary to control epistaxis and the provider uses an endoscope to treat the nasal bleeding while the patient is under anesthesia, you there is a combination code — 31238 (Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage) — you can use.

5. Ask, “Do I Need a Laterality Modifier?”

This is tricky, as the answer varies by procedure and payer. Anterior nosebleed hemostasis codes are unilateral. So, as 30901 and 30903 represent the treatment of one nostril, if the otolaryngologist controls anterior epistaxis in both nostrils, depending on payer preference, you’ll need to report the code:

• once with modifier 50 (Bilateral procedure)
• twice with modifier 50 appended to the second code
• with modifiers RT (Right side) and LT (Left side) on each code
• or with XS (Separate structure, a service that is distinct because it was performed on a separate organ/structure)

Conversely, posterior epistaxis control codes represent a bilateral service, which means it’s not appropriate to code either 30905 or 30906 with a laterality modifier.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC