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Otolaryngology Coding Alert

You Be the Coder:

Account for Epistaxis With Coumadin

Question: A new patient comes in to your office with a nosebleed. The otolaryngologist evaluates him and finds out that he is on Coumadin. The physician then attempts to control the bleeding with extensive anterior packing and cautery. How should you code the encounter?

New Jersey Subscriber

Answer: For the history, examination and medical decision-making that the otolaryngologist performed and documented for this new patient prior to performing bleed control, you should assign an office visit code (99201-99205). To indicate that the E/M service is significant and separately identifiable from the epistaxis, append modifier 25 to 9920x.

To choose the appropriate epistaxis code, first look at the bleed site: anterior. This detail produces two possible CPT codes: 30901 and 30903. Because the control involved extensive packing and cautery, you should use 30903. If the hemorrhage is extensive due to the patient's Coumadin use, consider appending modifier 22 (Unusual procedural services) to 30903.

In addition to the ICD-9 code for the hemorrhage (784.7, Epistaxis), you should report any documented comorbid conditions complicating the patient's care. Because the patient is on a blood-thinning medication that can affect the service and procedure, assign V58.61 (Long-term [current] use of anticoagulants) and possibly 286.5 (Hemorrhagic disorder due to intrinsic circulating anticoagulants).

Medicare considers V58.61 a secondary diagnosis. So list it as the second (if no 286.5) or third ICD-9 code in box 21 of the CMS-1500 form as follows:

1. 784.7
2. 286.5
3. V58.61. Link both 9920x-25 and 30903 to all diagnoses, such as 784.7, 286.5 and V58.61. In box 24 of the CMS-1500 form, you should enter:

D.  Procedures       Modifiers                      E. Diagnosis code                     G. Units  
      9920x                 25                                   1, 2, 3                                       1 
      30903                                                        1, 2, 3                                       1

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