tci Outpatient Facility Coding Alert - 2014 Issue 5

You Be the Coder: Coding for Nose Bleed

Question: A patient comes to a clinic after sustaining injuries during a soccer game. She had a black eye on the right side and her nose was bleeding from a direct hit from the ball. Upon her arrival the physician documented the detailed history, performed detailed examination, and made a medical decision of moderate complexity. The otolaryngologist could not stop the bleeding with ice or pressure, so to stop the bleeding a repeated and extensive cautery was performed with silver nitrate sticks on both nostrils. The physician ordered an X-ray to ensure that the patient’s nose was not...

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