Make E/M Decision First to Plug Nosebleed Coding Holes

Posted on 3 Jan, 2016 |comments_icon 1|By Chris Boucher
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If provider furnishes separate E/M before repair, remember 25.

When your physician stops a nosebleed, should you report an E/M service or CPT® code?

The answer: It depends. If the patient reports to the physician with complaints of a nosebleed, and the provider stops the bleed with conventional methods such as ice or pressure, you should report an E/M code for the service (99201-99215, depending on encounter specifics).

If, however, the provider employs more aggressive means of stopping the bleed, such as cautery or packing, you’ll typically choose a simple nosebleed repair code 30901 (Control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method).

Check for E/M-25 Possibility On 30901

If you’re reporting 30901  (Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method ) for a nosebleed repair, your physician could have provided an E/M service that you can also code — provided you include the right modifier. After all, the physician cannot know how to stop the bleeding before performing some kind of evaluation; this evaluation often amounts to an E/M service.

See also: Put 26 to Work for Many Off-Site Services

Example: An established patient comes to the office with a nosebleed that she has not been able to control for “about three hours.” After performing a problem focused history and exam to look for signs of a bleeding diathesis, the provider finds blood oozing from the right inferior nasal turbinate. The provider places a compressed nasal sponge in the affected nare, expanding it with a few drops of oxymetazoline, to control the bleeding.

On the claim, you would report 30901 for the nosebleed repair. Then, report 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) for the E/M service with 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 show that the provider performed a separately identifiable E/M service before stopping the nosebleed.

Author

Chris Boucher


Chris Boucher has nearly 10 years of experience writing various newsletters and other products for The Coding Institute. His blog will cover several areas of coding and compliance, including CPT® coding, modifiers, HIPAA compliance and ICD-10 coding.

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