When a patient presents with an active nosebleed, choosing the wrong code could lose you as much as $100.00 in reimbursement. Let’s look at an example:
An established patient presents after sustaining injuries playing soccer. A ball hits the patient’s face, which makes the nose bleed and gives him a black eye. You document a detailed history, exam and decision making is of moderate complexity. The patient is also complaining of a headache. You can’t stop the nose bleed with ice or pressure, so you perform extensive cautery using silver nitrate sticks on both nostrils, and repeat the procedure again. You order an x-ray to ensure the nose is not broken, the results come back negative. How should you code this?
Because you documentation is clearly defined on how your treated the nosebleed, using several attempts, reporting 30903 instead of 30901 (limited cautery and/or packing- defined as applied continuous pressure, inserted pledgets soaked with anesthetic-vasoconstrictor; administered nasal spray; chemical cautery, 1x only) you reimbursement would yield amount $100.00 more.
Make sure you choose the code that defines the services you performed. Remember if you stop the nose bleed simply by using ice, you would only report the E/M code.