Taylor Posted Fri 22nd of November, 2019 12:35:00 PM
Would you please code for the ED MD? Provided all documentation is present. Wondering if E/M-25, cpt 30901 is correct. Thanks much.
Patient is a 75-year-old female presenting with a nosebleed starting roughly 1/2-hour before presenting. She has had nosebleeds before and has seen ENT. She denies any trauma. She is not on any blood thinners. She denies any other bleeding and denies any bruising. Bleeding is from the left nare.
Patient is well appearing.
Head: Atraumatic. Symmetrical appearance.
Nose: Epistaxis (L nare).
Mouth: Moist mucous membranes.
Neck: Range of motion is painless. Neck is not stiff.
Rate & Rhythm: Regular rate. Regular rhythm.
Heart sounds: Normal S1. Normal S2.
Respiratory: Respiratory excursion is normal. Respiratory rate is normal.
Auscultation: Lungs are clear to auscultation.
Skin: Warm to touch. Skin is dry.
Medical decision making narrative: Patient 75-year-old female presenting with a nosebleed from the left nare. We did try Afrin and a nasal clamp without improvement at that point I did put silver nitrate and with packing. This did stop the bleeding. I did speak with Dr. A who she has seen before. Plan was to have her follow-up in the next 3 to 4 days to have the packing removed. She was started on Augmentin with a prescription. He was told if the bleeding returns to return emergency department or follow-up with ENT. She acknowledged understanding of the plan was discharged home. Antibiotic rx given.
SuperCoder Answered Mon 25th of November, 2019 07:43:17 AM
Thanks for your question.
As per the documentation available, code 99283 would be appropriate to use with modifier 25. CPT code 30901 should also be billed as ED physician controls nasal hemorrhage with silver nitrate and packing.
Hope this helps.
Taylor Posted Tue 26th of November, 2019 10:02:37 AM
It is sometimes hard for us to judge if there is a "significant, separately identifiable E&M service". Can you help explain to us how this example above qualifies for a E/M?
SuperCoder Answered Wed 27th of November, 2019 06:37:08 AM