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Shade Posted Wed 02nd of April, 2014 11:21:24 AM

FOR EXAMPLE: 99213 AND 30903

SuperCoder Answered Thu 03rd of April, 2014 09:57:17 AM


See as per the example:

based on this scenario:

An established patient reports to the office after sustaining injuries during a soccer game. A ball hits her in the face, which makes her nose bleed and gives her a black eye on the right side. The physician documents a detailed history, performs a detailed exam and medical decision making is of moderate complexity. The patient also complains of a headache and facial pain in addition to the nose bleed. The otolaryngologist cannot stop the bleeding with ice or pressure, so she performs repeated and extensive cautery using a silver nitrate stick on both nostrils. The bleeding finally stops, and the physician orders an x-ray to ensure that the patient's nose is not broken. Results came back negative from the x-ray. How should you report it?

You should be on the lookout for the type of nosebleed control your physician performs. In the above example, you should report the given scenario with:

30903 (Control nasal hemorrhage, anterior, complex [extensive cautery and/or packing] and method) for the complex repair
modifier 50 (Bilateral procedure) appended to 30903 to show that the physician treated both nostrils
99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity) for the E/M
modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99214 to show that the E/M and repair were separate services
784.0 (Headache and facial pain) appended only to the E/M service, 99214-25
784.7 (Epistaxis) appended to 30903 and 99214-25 to represent the patient's nosebleed
E917.0 (Striking against or struck accidentally by objects or persons; in sports without subsequent fall) appended to 30903 and 99214-25 to represent the cause of the patient's nosebleed
E007.5 (Activities involving other sports and athletics played as a team or group; soccer) appended to 30903 and 99214-25 to represent the circumstances surrounding the patient's nosebleed.

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