Don’t Overstuff This Brief Visit
Question: How should I code the following? An established patient was brought into the office by their parents with mild anterior bleeding in the left nostril. The physician performed a history and exam, and then they applied direct pressure to the affected nostril before inserting a small packing of gauze into it. The provider then removed the packing after a few minutes, examined the patient’s left nostril a second time, and noted the bleeding had stopped. The patient was then sent home with no further instructions. AAPC Forum Participant Answer: For the above scenario, you would simply code for the evaluation and management (E/M) portion using 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making…). Even though the provider temporarily packed the patient’s nostril with gauze to staunch the bleeding, you won’t be able to use code 30901 (Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method) because “there was no cautery performed or packing left in place to remain after the encounter,” per CPT® Assistant (Volume 30, Number 7). The patient was sent home with an empty nostril and no follow-up instructions as stated in the notes. To show the payer the service was medically necessary, you should still report ICD-10-CM code R04.0 (Epistaxis), however. Lindsey Bush, BA, MA, CPC, Production Editor, AAPC
