burnam
Contributor
Good Morning!
We had a claim reject in our coding scrubber software stating a modifier was needed. I viewed the codes that were billed and the manager in the office forgot to add a 25 modifier to the E/M code that was billed with a procedure that has a 10-day global period. I went back and reviewed the documentation to see if a 25 modifier could be used based on the documentation. The physician billed a 99202 and 30903. This is the note without patient information. I would like for someone else's opinion on this. I personally don't think that the procedure documented warrants coding 30903, if anything, it would be 30901, but I am not sure how to explain this to the physician as he is older and set in his ways. I would greatly appreciate any assistance/guidance. Thank you in advance.
Chief Complaint: NOSEBLEED
Subjective:
This 71 years old male presents for evaluation of the following problem(s): Patient was sent here from the ER to take the packing out of his nose. Patient states that he started having a nosebleed yesterday morning and could not control it at home. He went to the ER and had the nosebleed controled with packing. He was then told to come see us today to have the packing removed from his nose. He is not currently bleeding at this time but states that his nose is running.
1. EPISTAXIS/NOSEBLEEDS
Duration: 1 day
Frequent nose picking: no
Recurrent nosebleeds: no
Current anticoagulation therapy: yes
History of bleeding diathesis: no
Previous ENT evaluation: no
Treatments attempted: Went to ER had nose packed
Review of Systems:
Constitutional: negative
Eyes: negative
Ears: negative
Nose: negative
Mouth/Throat: negative
Cardiovascular: negative
Respiratory: negative
Gastrointestinal: negative
Genitourinary: negative
Musculoskeletal: negative
Skin: negative
Breast: negative
Neurological: negative
Psychiatric: negative
Hematologic/Lymphatic: negative
Allergic/Immunologic: negative
Past Medical History:
Past Medical History:
.MP: HYPERTENSION NOS: 401.9
.MP: HEART ATTACK
Surgical / Procedural History:
.PR: EYE SURGERY
Social History:
Alcohol: none
Family History:
Current Medications:
Current Medications:
Rx: COUMADIN 2MG 1 TAB daily - days, 30, Ref: 0
Rx: LISINOPRIL 40MG 1 TAB daily - days, 30, Ref: 0
Rx: AMPICILLIN 500MG four times daily 1 days, , Ref: 0
Medication Allergies:
Allergies:
NKDA
Objective:
General: Ill-appearing , with mild distress from having his nose packed but no respiratory distress
Skin: no rash or prominent lesions
Head: normocephalic, atraumatic
Ears: Ear canals clear, tympanic membranes clear, ossicles normal appearance.
Nose: A tampon is in his right nostril-It was removed and old blood and secretions aspirated
Mucosa: a gouged area is seen in the anterior area. It was anesthetized and treated with silver nitrate
Septum: deviated left
Secretions: clear with old blood
Turbinates: within normal limits
Polyps:
Mouth: Mucous membranes moist, no mucosal lesions.
Dentition: poor oral hygiene is evident.with multiple badly decayed teeth
Throat: Pharynx: No erythema. no blood
Tonsils: absent
Neck: Supple without lymphadenopathy. Thyroid is normal size without nodules or tenderness.
Assessment:
.DX: EPISTAXIS : 784.7
.DX: UNSPECIFIED ESSENTIAL HYPERTENSION : 401.9
Plan:
Explained in detail to pt. and daughter how to control bleeding should it reoccur
.PR: CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX : 30903
Follow-up: PRN
We had a claim reject in our coding scrubber software stating a modifier was needed. I viewed the codes that were billed and the manager in the office forgot to add a 25 modifier to the E/M code that was billed with a procedure that has a 10-day global period. I went back and reviewed the documentation to see if a 25 modifier could be used based on the documentation. The physician billed a 99202 and 30903. This is the note without patient information. I would like for someone else's opinion on this. I personally don't think that the procedure documented warrants coding 30903, if anything, it would be 30901, but I am not sure how to explain this to the physician as he is older and set in his ways. I would greatly appreciate any assistance/guidance. Thank you in advance.
Chief Complaint: NOSEBLEED
Subjective:
This 71 years old male presents for evaluation of the following problem(s): Patient was sent here from the ER to take the packing out of his nose. Patient states that he started having a nosebleed yesterday morning and could not control it at home. He went to the ER and had the nosebleed controled with packing. He was then told to come see us today to have the packing removed from his nose. He is not currently bleeding at this time but states that his nose is running.
1. EPISTAXIS/NOSEBLEEDS
Duration: 1 day
Frequent nose picking: no
Recurrent nosebleeds: no
Current anticoagulation therapy: yes
History of bleeding diathesis: no
Previous ENT evaluation: no
Treatments attempted: Went to ER had nose packed
Review of Systems:
Constitutional: negative
Eyes: negative
Ears: negative
Nose: negative
Mouth/Throat: negative
Cardiovascular: negative
Respiratory: negative
Gastrointestinal: negative
Genitourinary: negative
Musculoskeletal: negative
Skin: negative
Breast: negative
Neurological: negative
Psychiatric: negative
Hematologic/Lymphatic: negative
Allergic/Immunologic: negative
Past Medical History:
Past Medical History:
.MP: HYPERTENSION NOS: 401.9
.MP: HEART ATTACK
Surgical / Procedural History:
.PR: EYE SURGERY
Social History:
Alcohol: none
Family History:
Current Medications:
Current Medications:
Rx: COUMADIN 2MG 1 TAB daily - days, 30, Ref: 0
Rx: LISINOPRIL 40MG 1 TAB daily - days, 30, Ref: 0
Rx: AMPICILLIN 500MG four times daily 1 days, , Ref: 0
Medication Allergies:
Allergies:
NKDA
Objective:
General: Ill-appearing , with mild distress from having his nose packed but no respiratory distress
Skin: no rash or prominent lesions
Head: normocephalic, atraumatic
Ears: Ear canals clear, tympanic membranes clear, ossicles normal appearance.
Nose: A tampon is in his right nostril-It was removed and old blood and secretions aspirated
Mucosa: a gouged area is seen in the anterior area. It was anesthetized and treated with silver nitrate
Septum: deviated left
Secretions: clear with old blood
Turbinates: within normal limits
Polyps:
Mouth: Mucous membranes moist, no mucosal lesions.
Dentition: poor oral hygiene is evident.with multiple badly decayed teeth
Throat: Pharynx: No erythema. no blood
Tonsils: absent
Neck: Supple without lymphadenopathy. Thyroid is normal size without nodules or tenderness.
Assessment:
.DX: EPISTAXIS : 784.7
.DX: UNSPECIFIED ESSENTIAL HYPERTENSION : 401.9
Plan:
Explained in detail to pt. and daughter how to control bleeding should it reoccur
.PR: CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX : 30903
Follow-up: PRN