👩🏾‍⚕️ CPT Code 30905 — Control of Posterior Nasal Hemorrhage, Initial

Official Full Descriptor

Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial

CPT 30905 captures the first treatment session for a posterior nasal hemorrhage using posterior nasal packing, cautery, or any combination of these methods. The term “initial” is a critical element of the descriptor — it designates this as the first encounter at which posterior packing or cautery is applied for a posterior bleed. If the same patient requires a return visit for reapplication of posterior packing due to treatment failure or rebleeding, report CPT 30906 (subsequent) instead. The phrase “any method” means that the specific technique used — bilateral gauze posterior packs, double-balloon catheter (Epistat), single-balloon device (Rapid Rhino posterior), endoscopically-guided posterior cautery prior to formal endoscopic ligation — does not alter the code, provided no endoscope is used as the active therapeutic instrument.

Code Classification & Position in the CPT Hierarchy

Respiratory System (10000-32999)
 └── Nose (30000-30999)
      └── Other Procedures on the Nose (30901-30999)
           └── Control of Nasal Hemorrhage (30901-30906)
                ├── 30901  Anterior, simple (limited cautery and/or packing)
                ├── 30903  Anterior, complex (extensive cautery and/or packing)
                ├── 30905  Posterior, initial (packs and/or cautery) ← TARGET
                └── 30906  Posterior, subsequent (packs and/or cautery)

Full Epistaxis Control Code Family — Complete Reference

CPT	Descriptor	Location	Complexity	wRVU (approx.)	Global
30901	Control nasal hemorrhage, anterior, simple	Anterior	Simple	~1.31	0 days
30903	Control nasal hemorrhage, anterior, complex	Anterior	Complex	~2.42	0 days
30905	Control nasal hemorrhage, posterior; initial	Posterior	First treatment	~3.01	0 days
30906	Control nasal hemorrhage, posterior; subsequent	Posterior	Repeat treatment	~3.88	0 days

Escalation Procedures — Separately Reportable When 30905 Fails

CPT	Description	Context	wRVU (approx.)
31238	Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage	Endoscope is active treatment instrument (not just for visualization)	~4.84
31241	Nasal/sinus endoscopy, surgical; with ligation of sphenopalatine artery(ies) (TESPAL)	Endoscopic sphenopalatine artery ligation	~9.53
30920	Ligation, internal maxillary artery; transantral approach	Open/endoscopic arterial ligation — internal maxillary	~8.70
61626	Transcatheter occlusion/embolization, non-CNS; head or neck	Interventional radiology embolization for refractory epistaxis	~12.00+

Tip

Key escalation principle: When posterior packing (30905) fails and the patient requires surgical or endoscopic intervention, the appropriate escalation code (31238, 31241, 30920) is reported. CPT 30905 and the escalation code may both be reported if packing was initially applied at one encounter and the definitive surgical intervention occurs at a separate, distinct encounter. If both occur at the same session, the higher-value surgical code is generally reported, as the packing is integral to the surgical procedure. Verify NCCI edits and payer policy when reporting same-session packing plus endoscopic intervention.

Procedure Description — What CPT 30905 Represents

Clinical Definition

CPT 30905 describes the first intervention performed to control a posterior nasal hemorrhage using bilateral posterior nasal packing, cautery of the posterior nasal cavity, or a combination of these techniques. It is the most clinically significant code in the epistaxis family because posterior nasal hemorrhage — unlike anterior epistaxis — is associated with higher blood loss, higher rates of inpatient admission, greater risk of airway compromise, and a more complex patient population (older, more comorbidities, more frequent anticoagulation).

Posterior epistaxis most commonly arises from the sphenopalatine artery (SPA) or its branches, particularly at the sphenopalatine foramen on the lateral nasal wall and the posterior nasal septum at the posterior nasal septum’s vascular anastomoses. The SPA is the terminal branch of the internal maxillary artery, itself a branch of the external carotid artery. Less commonly, posterior epistaxis arises from the posterior ethmoidal artery (a branch of the ophthalmic artery from the internal carotid system), which is important because embolization does not address ICA-derived vessels, making surgical ligation the only option for posterior ethmoidal artery bleeds.

Anatomy — Posterior vs. Anterior Epistaxis

Posterior Epistaxis:

Originates in the posterior nasal cavity, at or behind the posterior end of the inferior turbinate, from branches of the sphenopalatine artery or posterior ethmoidal artery
Blood flows posteriorly into the nasopharynx; patient may swallow blood, present with hematemesis, or have blood visible in the posterior pharynx
Not visible on anterior rhinoscopy or speculum exam; typically only identifiable with nasopharyngoscopy or nasal endoscopy
Represents approximately 5-10% of all epistaxis cases but accounts for a disproportionately high share of hospitalizations, transfusions, and intensive interventions
More common in older adults with hypertension, atherosclerosis, and anticoagulation

Clinical Features Distinguishing Posterior from Anterior Epistaxis:

Blood drains down the posterior pharynx rather than from the nasal aperture
Anterior packing alone does not control bleeding (blood continues to flow posteriorly or into the pharynx despite anterior packing)
Patient may gag on blood, present with hematemesis, or require oral suctioning
Bilateral blood tracking even when unilateral packing placed
BP is often significantly elevated at presentation
In elderly patients on anticoagulation, posterior bleeds are associated with Hgb drops requiring transfusion in a significant minority of cases

The Posterior Nasal Space: Anatomical Boundaries of Packing

Posterior nasal packing works by filling the choana — the posterior aperture of the nasal cavity where it communicates with the nasopharynx — to create a posterior tamponade stop that prevents blood from flowing posteriorly while anterior pressure is simultaneously applied through anterior packing. The posterior pack provides the posterior wall against which the anterior pack can compress.

Classic four-layer anatomy relevant to posterior packing:

Nasal cavity proper (anterior to choana)
Choanal aperture (the posterior opening)
Nasopharynx (behind the choana, above the soft palate)
The posterior nasal septum vasculature (common posterior bleed origin)

Methods — “Any Method” Under 30905

All of the following techniques fall under CPT 30905 when used for initial posterior epistaxis control. The specific device or technique does not change the code:

Formal Posterior Gauze Packs (Traditional / Classic Method):

Rolled petroleum gauze (Vaseline-impregnated) formed into a dense oblong pack, delivered into the posterior choana via the mouth using a posterior pack catheter or suture tie
Historically the most common method; highly effective but uncomfortable, associated with significant morbidity (hypoxemia, pressure necrosis, sinusitis, otitis media, pain)
Requires string anteriorly through the nose and posteriorly through the mouth for secure fixation; string is taped to the patient’s nose
Virtually replaced in modern practice by balloon devices but remains relevant for complex anatomy

Balloon Tamponade Devices — Dual-Balloon (Epistat / Brighton Balloon):

Double-balloon catheter (anterior + posterior balloon on a single shaft)
Posterior balloon is inflated in the nasopharynx (10-20 mL water or saline) to act as the posterior stop, then the anterior nasal balloon is inflated (30-45 mL) to fill the nasal cavity
Most widely used method in emergency and inpatient settings
Key: The posterior balloon must be inflated first, then the anterior balloon; inflating the anterior balloon first without posterior stop risks posterior balloon displacement

Posterior-Only Packs with Separate Anterior Gauze:

Some providers prefer to place a traditional gauze posterior pack in combination with a separate Merocel tampon anteriorly for independent pressure control

Foley Catheter as Posterior Pack:

A 14-16 French Foley catheter introduced transnasally into the nasopharynx, balloon inflated (5-10 mL), and pulled forward to sit at the posterior choanal opening
Improvised technique used when formal posterior packing devices are unavailable; widely used in resource-limited or high-acuity settings
Effective and inexpensive; shares the same CPT code (30905) as formal posterior packing devices

Posterior Cautery (Limited Endoscopic or Blind):

In select cases where the posterior bleeding site is visible via nasal endoscopy, direct cautery may be applied to the bleeding vessel before formal posterior packing
If cautery alone is used (without leaving a pack) but the bleeding is confirmed posterior and the cautery is applied in the posterior nasal cavity, 30905 remains appropriate
If the nasal endoscope is the active treatment instrument (used to guide cautery directly), consider whether 31238 is more appropriate — see NCCI section

Topical Hemostatic Agents:

Tranexamic acid (TXA) intranasal spray or soaked pledgets — increasingly used as adjunct; does not replace packing but may reduce pack size needed
FloSeal/Surgiflo with or without packing — placed in the posterior nasal cavity or at the site of bleeding identified endoscopically
These agents fall under “any method” and do not change the code to something other than 30905

Includes

The following components are bundled into 30905 and cannot be separately billed:

Application of posterior nasal pack (any type: gauze, balloon, Foley catheter) as the primary hemostatic mechanism
Placement of anterior nasal packing when done as part of the same session to provide anterior tamponade support for the posterior pack — the anterior packing is integral and subsumed by 30905
Topical vasoconstrictor/anesthetic application prior to packing (e.g., lidocaine + oxymetazoline pledgets)
Oral/nasal suctioning to clear blood prior to pack placement
Diagnostic visualization of the posterior nasal space via nasal speculum or rigid nasal endoscope when used solely for visualization of the bleeding site before applying the posterior pack
Posterior pack securing technique (strings, suture ties, taping to the nose)
Foley catheter balloon inflation and positioning (subsumed into 30905 — no separate catheter placement code applies)
Patient monitoring and vital sign management during the procedure
Post-procedure care instructions within the 0-day global period
Anterior epistaxis treatment (30901/30903) performed at the same session — anterior codes are bundled into 30905 by NCCI; see Excludes section

Excludes / Do Not Report Together

NCCI Bundles — Critical Rules for 30905

Code	Description	Relationship to 30905	Modifier Override
30901	Anterior epistaxis, simple	Bundled INTO 30905 — if both anterior and posterior treatment performed same session, report only 30905	None — cannot override
30903	Anterior epistaxis, complex	Bundled INTO 30905 — same session; 30905 is more comprehensive	None — cannot override
30906	Posterior epistaxis, subsequent	Mutually exclusive with 30905 at same encounter — 30905 = initial; 30906 = repeat. Cannot bill both at same encounter	None

Note

Plain Language Rule: If anterior AND posterior packing/cautery are performed at the same session for the same patient, report only 30905. The anterior component is wholly included. This is one of the most violated rules in epistaxis coding.

30905 vs. 31238 — The Endoscope Decision Point

This is the single most nuanced distinction in posterior epistaxis coding:

Scenario	Correct Code
Nasal endoscope used to visualize the posterior bleeding site, then posterior pack placed by any method	30905 — endoscope is just a visualization tool
Nasal endoscope used to actively cauterize the bleeding vessel at the posterior lateral nasal wall (e.g., bipolar cautery through endoscope, no pack placed afterward, or pack placed only to confirm hemostasis)	31238 — endoscope is the active treatment instrument
Diagnostic endoscopy performed in clinic earlier the same day, then posterior packing in ED	31231 (diagnostic scope) + 30905 (packing) with appropriate modifiers and separate encounter documentation — verify payer

Tip

When in doubt: Ask the provider whether the endoscope was used to actually deliver the treatment (31238) or merely to see the bleeding site before applying a separate treatment (30905). This single question determines correct code selection.

30905 vs. 31241 (TESPAL — Transnasal Endoscopic Sphenopalatine Artery Ligation)

Scenario	Code
Posterior packing placed as initial measure	30905
Posterior packing failed; patient taken to OR for endoscopic SPA ligation	31241 (separately at a different encounter/OR session)
Posterior packing AND endoscopic SPA ligation performed at same session	Typically only 31241 — the packing is integral to the surgical field preparation and management; however, some payers may allow both with modifier -59/XS if the packing was placed at a distinct prior encounter; verify payer policy

Do Not Append Modifier -50 to 30905

CPT 30905 is inherently bilateral. Posterior nasal packing tamponades the choana and posterior nasal space in a fashion that provides bilateral tamponade by anatomical necessity. The concept of unilateral posterior packing does not apply to the classical posterior epistaxis packing techniques. Never append modifier -50 to 30905 or 30906. This is a specific and commonly seen coding error when providers migrate assumptions from anterior codes (where -50 IS applicable for bilateral anterior treatment) to posterior codes.

Additional Codes That Should NOT Be Reported with 30905

Code	Description	Reason
31231	Diagnostic nasal endoscopy	If used purely for visualization before packing, it is bundled into 30905; report 31231 separately only if performed at a distinct prior encounter
99213-99215 without -25	E&M on same day	E&M is separately reportable but REQUIRES modifier -25; without -25, it will be denied

HCC (Hierarchical Condition Category)

Field	Detail
HCC Mapped	No — CPT 30905 is a procedure code; procedure codes do not carry HCC weight
HCC via Diagnosis	The ICD-10-CM diagnoses paired with 30905 may carry HCC significance. R04.0 (Epistaxis) itself is not an HCC code. However, underlying etiologies that are HCC-relevant include: C32.0-C32.9 (laryngeal/sinonasal malignancy), C30.0 (nasal cavity malignancy), D65 (DIC), D66-D67 (hemophilia A/B), D68.x (coagulopathy), I78.0 (HHT/Osler-Weber-Rendu disease), and hematologic malignancies (C81-C96). Always code the confirmed underlying cause — not just R04.0 — to capture HCC risk where applicable.
High-Value HCC Pairing	When posterior epistaxis in an elderly Medicare patient is secondary to a known malignancy or hemophilia, coding the underlying diagnosis alongside R04.0 generates HCC credit and more accurately reflects the patient’s true risk burden.

wRVU (Work Relative Value Units)

Component	Facility Setting	Non-Facility Setting
Work RVU (wRVU)	~3.01	~3.01
Practice Expense RVU	~2.19	~4.89
Malpractice RVU	~0.12	~0.12
Total RVU (facility)	~5.32	~8.02 (non-facility)

Approximate Medicare National Payment:

Facility (ED, hospital): ~ $172 (T o t a lR V U 5.32 \times CF$ 32.35)
Non-facility (office): ~ $259 (T o t a lR V U 8.02 \times CF$ 32.35)

Epistaxis Code Family wRVU Comparison:

CPT	Description	wRVU (approx.)
30901	Anterior, simple	~1.31
30903	Anterior, complex	~2.42
31231	Diagnostic nasal endoscopy	~1.43
30905	Posterior, initial	~3.01
30906	Posterior, subsequent	~3.88
31238	Endoscopic hemorrhage control	~4.84
31241	TESPAL (SPA ligation)	~9.53
30920	Internal maxillary artery ligation	~8.70

Note

30906 (subsequent) carries a higher wRVU than 30905 (initial) despite being a repeat procedure. This reflects the AMA RUC’s recognition that a second posterior epistaxis treatment indicates treatment failure, requiring more clinical judgment, greater physician work to assess the situation, and often more complex re-intervention. This counterintuitive relationship is worth explaining to providers who may question why the “second” procedure pays more.

Always verify against the current year’s CMS MPFS Addendum B. Values are subject to annual revision.

Assistant Payable

Field	Detail
Medicare Assistant-at-Surgery	No — Not Payable
Medicare Indicator	0 — assistant not payable under any circumstance
Rationale	CPT 30905 is performed at the bedside, in the ED, or in a procedure room by a single physician. Posterior nasal packing, Foley catheter balloon placement, and bedside posterior cautery are single-operator procedures. No surgical assistant has a defined clinical role.
Co-surgeon	Not applicable
Commercial Payers	No commercial payer reimburses an assistant for posterior nasal packing.
Anesthesia Note	30905 does not require general or MAC anesthesia in standard practice. Procedural sedation may be used in select patients (anxious, pediatric, or combative patients). Anesthesia, if provided, would be a separate service under the anesthesiologist’s billing.

Global Period — 0 Days

All four epistaxis control codes (30901, 30903, 30905, 30906) carry a 0-day global period, confirmed by CMS. This has critical implications for multi-day posterior packing management, which is one of the most common inpatient epistaxis scenarios.

What 0-Day Global Period Means for Posterior Epistaxis

The 0-day global period means:

No pre-operative visit is bundled — a separately documented E&M on the day of the procedure is separately billable with modifier -25
No post-operative care is bundled — E&M visits on the following days of an inpatient stay are separately billable without any modifier (the global period has already closed on the day of the procedure)
Same-day re-packing: If posterior packing is placed, re-examined, or replaced on the same day by the same physician, a second 30905 or 30906 may be reported with modifier -76 (repeat procedure, same physician)
Next-day visits: Because the global period is 0 days, subsequent hospital visits (99231-99233) or subsequent pack-related interventions on the following days do not require a modifier to indicate they are outside the global period — they are already outside it

Multi-Day Inpatient Packing Scenario

Patients admitted with posterior packs in place for 48-72 hours (a common management strategy) can have each clinical encounter during the admission separately billed:

Day	Event	Billable Code
Day 1	Posterior pack placed	30905
Day 1 continued	Separate, documented E&M assessing medical comorbidities	99232-25 or 99232 (if a truly distinct E&M)
Day 2	Subsequent inpatient visit, monitoring pack and O₂	99231-99233 (inpatient subsequent care E&M)
Day 2	Pack repositioned due to displacement	30906 (subsequent)
Day 3	Pack removal — ENT documents exam	99231 or 99232
Day 3	New pack placed due to rebleed	30906 (subsequent)

Note

The 0-day global is the single most important billing concept for posterior epistaxis in the inpatient setting. Many coders and providers incorrectly assume there is a bundled post-operative period and do not bill the daily hospital management or subsequent pack-related procedures. This results in significant lost revenue that is entirely appropriate to capture.

Site of Service (SOS)

Setting	Applicable	Notes
Emergency Department	Yes — most common setting for initial posterior packing	Facility rate applies; physician bills professional component; very common setting for 30905
Hospital Inpatient (Bedside)	Yes — common for admitted patients	Facility rate applies; physician bills separately; multi-day packing scenarios fully separately billable due to 0-day global
Hospital Outpatient / HOPD	Yes	Facility bills APC; physician bills professional component
Office / Clinic	Rarely — only for mild posterior bleeds in controlled setting with immediate escalation capability	Non-facility rate applies; much higher payment to physician who bears supply costs
ICU / MICU	Yes — as inpatient bedside setting	Critical care billing (99291-99292) may also be appropriate if physician spends ≥30 minutes in critical care management; evaluate whether 30905 or critical care is the primary service to bill
Ambulatory Surgery Center	Rare	For posterior cautery under endoscopy (31238) rather than simple posterior packing (30905)

MS-DRG Assignment

Posterior epistaxis requiring inpatient admission is a common ENT-driven hospitalization. The MS-DRG assignment depends on the principal ICD-10-CM diagnosis and any CC/MCC secondary diagnoses.

Primary DRG Family — MDC 03 (Ear, Nose, Mouth and Throat)

When R04.0 (Epistaxis) is the principal diagnosis and no OR-level procedure is performed:

MS-DRG	Title	CC/MCC
153	Otitis Media and URI with MCC	With MCC
154	Otitis Media and URI without MCC	Without MCC

Important DRG Note:

R04.0 (Epistaxis) with posterior packing (30905) typically does not qualify as an OR-level procedure under the IPPS grouper. CPT 30905 maps to a bedside/non-OR procedure type, meaning the admission groups to the medical DRG (153/154) based on the diagnosis alone rather than a surgical DRG. This is a critical inpatient coding and CDI concept — posterior packing alone will not drive an OR-level DRG.

When Posterior Epistaxis Groups to Higher DRGs

Trigger	MS-DRG Impact
Endoscopic hemorrhage control (31238) performed	May qualify as OR procedure; escalates to DRG 579/580/581 (Other ENT OR Procedures)
Endoscopic SPA ligation / TESPAL (31241) performed	OR procedure; groups to DRG 579/580/581
Arterial embolization (61626) performed	OR procedure under IR; may group differently depending on principal diagnosis
Open arterial ligation (30920)	OR procedure; DRG 579/580/581 or tracheostomy DRG if airway involved
Blood transfusion required	Transfusion is not an OR procedure but coagulopathy as secondary diagnosis may function as MCC/CC and elevate DRG tier

DRG Shift When Etiology Governs Principal Diagnosis

Principal Diagnosis	MDC	DRG Family
R04.0 (Epistaxis, idiopathic)	MDC 03	153/154
D69.6 (Thrombocytopenia)	MDC 16	Blood/blood-forming DRGs
D65 (DIC)	MDC 16	Blood DRGs (MCC)
C30.0 (Nasal cavity malignancy)	MDC 03	146/147/148 (ENT Malignancy)
C44.321 (SCC nose)	MDC 03	146/147/148
I78.0 (HHT)	MDC 03	153/154
I16.1(Hypertensive emergency)	MDC 05	Circulatory DRGs
T45.515A (Adverse effect anticoagulants)	MDC 21 (Injuries/Toxicology)	Poisoning/Toxic Effect DRGs

CDI Opportunity: When a patient is admitted for severe posterior epistaxis in the setting of a known coagulopathy, malignancy, or hypertensive emergency, the underlying condition should be the principal diagnosis (the condition chiefly responsible for the admission after study). Sequencing epistaxis as principal when the coagulopathy drove the admission results in a lower DRG relative weight. CDI specialists and coders should query providers about which condition was most responsible for the admission to ensure accurate principal diagnosis sequencing.

CC/MCC Status of Secondary Diagnoses Paired with 30905

R04.0 (Epistaxis) itself is not a CC or MCC as a secondary diagnosis. However, the following frequently co-occurring secondary diagnoses may function as CC or MCC and elevate the DRG tier:

Secondary Diagnosis	CC/MCC Status
D65 — DIC	MCC
D68.311 — Acquired hemophilia	MCC
D66 — Hereditary factor VIII deficiency (Hemophilia A)	CC
D67 — Hereditary factor IX deficiency (Hemophilia B)	CC
D68.0 — Von Willebrand disease	CC
D69.3 — ITP	CC
I16.1 — Hypertensive emergency	MCC
I16.0 — Hypertensive urgency	CC
T45.515A — Adverse effect anticoagulants, initial	CC
J96.00 — Acute respiratory failure	MCC
N18.4 — CKD stage 4	CC
N18.5 — CKD stage 5	MCC
I50.9 — Heart failure, unspecified	CC
E11.649 — T2DM with hypoglycemia without coma	CC

Note

Accurate identification and coding of these secondary diagnoses not only improves risk adjustment but may shift the DRG from 154 (without MCC) to 153 (with MCC), materially increasing the hospital’s reimbursement.

Commonly Paired ICD-10-CM Diagnosis Codes

Primary Diagnosis

ICD-10-CM	Description	Notes
R04.0	Epistaxis	Primary code — nosebleed; includes hemorrhage from nose; not a CC or MCC

Systemic/Vascular Causes

ICD-10-CM	Description	HCC	CC/MCC
I10	Essential hypertension	No	Not CC
I16.0	Hypertensive urgency	No	CC
I16.1	Hypertensive emergency	No	MCC
I78.0	Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu)	No	Not CC
I77.1	Stricture of artery	No	—

Coagulopathy

ICD-10-CM	Description	HCC	CC/MCC
D65	DIC (disseminated intravascular coagulation)	No	MCC
D66	Hereditary factor VIII deficiency (Hemophilia A)	No	CC
D67	Hereditary factor IX deficiency (Hemophilia B)	No	CC
D68.0	Von Willebrand disease	No	CC
D68.311	Acquired hemophilia	No	MCC
D68.32	Hemorrhagic disorder due to extrinsic anticoagulants	No	CC
D69.3	Immune thrombocytopenic purpura (ITP)	No	CC
D69.6	Thrombocytopenia, unspecified	No	CC

ICD-10-CM	Description	Sequencing
T45.515A	Adverse effect of anticoagulants, initial encounter	After principal Dx; drug correctly prescribed and administered
T45.525A	Adverse effect of antithrombotic drugs, initial encounter	For antiplatelet agents
Z79.01	Long-term use of anticoagulants	Secondary — ongoing status
Z79.02	Long-term use of antithrombotics	Secondary

Note

Adverse Effect Sequencing: When posterior epistaxis is caused by correctly prescribed and administered anticoagulant therapy (warfarin, DOAC, heparin), the epistaxis is the manifestation and is coded first (R04.0 as principal if it is the reason for admission), followed by the adverse effect code (T45.515A) and then the underlying condition being treated by the anticoagulant (e.g.,I48.91 — atrial fibrillation). This three-code sequence is required per ICD-10-CM guidelines for adverse effect coding.

Nasal/Sinus Structural Causes

ICD-10-CM	Description
J34.2	Deviated nasal septum
J34.89	Other specified disorders of nose and nasal sinuses
J31.0	Chronic rhinitis

ICD-10-CM	Description	HCC
C30.0	Malignant neoplasm of nasal cavity	Yes
C31.0	Malignant neoplasm of maxillary sinus	Yes
C31.1	Malignant neoplasm of ethmoidal sinus	Yes
C44.321	SCC, skin of nose	Yes
C79.89	Secondary malignant neoplasm, other sites	Yes
C81-C96	Hematologic malignancies (leukemia, lymphoma)	Yes

Trauma

ICD-10-CM	Description
S09.90XA	Unspecified injury of head, initial encounter
S09.92XA	Unspecified nasal fracture
S02.2XXA	Fracture of nasal bones, initial encounter

Modifier Considerations for CPT 30905

Modifier	Usage with 30905
-25	Required when billing an E&M service on the same date as 30905; the E&M must be separately documented and represent a distinct, significant service beyond the packing
-50	DO NOT USE — 30905 is inherently bilateral; applying modifier -50 is incorrect and will result in overpayment or claim issues
-76	Repeat procedure, same physician, same day — use when posterior packing is re-placed on the same date by the same provider (e.g., pack fell out and was replaced within same calendar day); second unit of 30905 with -76
-77	Repeat procedure, different physician, same day — use when a second provider replaces the pack on the same date (e.g., ENT places initial pack in ED, hospitalist replaces it later same night)
-RT / -LT	Generally not applicable — posterior packing is bilateral by nature; however, some payers request laterality documentation for localized posterior cautery (e.g., endoscopic cautery of posterior septum on one side); verify per payer
-59 / -XE	Use to separate a distinct endoscopic procedure (31238) from 30905 if both are performed at distinct anatomical sites or separate encounters; carefully document and verify NCCI
-79	Unrelated procedure during the global period of a different procedure — posterior epistaxis packing occurring during the global period of an unrelated surgical procedure; note that 30905 has a 0-day global itself, so this modifier is only needed in relation to other active global periods

Packing Removal — Is It Separately Billable?

This is one of the most commonly asked coding questions for posterior epistaxis management and deserves dedicated attention:

Removal of posterior packing that was placed at a prior encounter:

If the same physician who placed the packing removes it at a follow-up visit, the removal is generally not separately billable unless the encounter involves significant, documented evaluation and management beyond the packing removal itself
Because 30905 has a 0-day global period, the “global period” concept does not bundle the removal into the original procedure’s fee — however, Medicare historically does not recognize a separate CPT code for packing removal from the nose
An E&M (office visit or subsequent hospital care) may be billed for the removal visit if it includes separately documented evaluation, examination, and medical decision-making distinct from the mechanical act of removing the pack
Removal of packing placed by a different physician at a different facility: E&M is the appropriate billing vehicle; document the clinical encounter clearly

Note

No CPT code specifically covers “nasal pack removal” — the E&M is the appropriate vehicle for this encounter.

Relationship to 31241 — TESPAL (Transnasal Endoscopic Sphenopalatine Artery Ligation)

CPT 31241 (introduced in 2018) specifically describes endoscopic SPA ligation and is the current gold standard for refractory posterior epistaxis. The relationship between 30905 and 31241 in clinical and coding practice:

Scenario	Coding
Initial posterior packing placed in ED; resolves without further intervention	30905 only
Initial posterior packing placed; fails; taken to OR for endoscopic SPA ligation at separate session	30905 (initial packing session) + 31241 (OR session — separate claim/encounter)
Initial posterior packing AND endoscopic SPA ligation performed at same operative session	Generally 31241 only — packing integral to surgical setup; however some payers may allow both; verify
Patient has bilateral posterior bleeds; bilateral SPA ligation performed	31241 (bilateral by definition; check code descriptor)

Coding Guidelines, Rules & Common Errors

Rule 1 — Anterior + Posterior Same Session = 30905 Only

When both anterior and posterior packing or cautery are performed at the same encounter, report only 30905. The anterior component (30901 or 30903) is bundled by NCCI into 30905. Never report 30901, 30903, AND 30905 together for the same session. This is the most common epistaxis coding compliance error.

Rule 2 — Initial vs. Subsequent: Date of Service Governs

30905 = first time posterior packing is placed at this episode of care. 30906 = any subsequent posterior packing placement for the same episode. If a patient has packs placed on Day 1 (30905) and the pack is replaced due to rebleed on Day 2 (30906) and replaced again on Day 3 (30906 again), each day’s intervention is separately billable because the 0-day global period means there is no bundled post-op period. This generates legitimate multi-line billing that is fully supported.

Rule 3 — “Initial” Does Not Reset for Readmission

If a patient has posterior packing placed during one admission (30905), is discharged, and returns within days for rebleed with new posterior packing, the second admission’s packing is 30906 (subsequent), not a new 30905 (initial). The episode of care continues regardless of discharge. This is a judgment call — if sufficient time has passed (weeks to months) and a truly new, distinct episode of posterior epistaxis has occurred, 30905 may be appropriate; consult payer guidelines and document the clinical reasoning.

Rule 4 — Same-Day E&M Requires Modifier -25

Because 30905 has a 0-day global period, an E&M service on the same day IS separately billable, but the E&M must be distinct, separately documented, and appended with modifier -25. Without -25, the E&M will automatically deny as bundled with the procedure. Document the E&M separately from the packing note.

Rule 5 — No Modifier -50 for Posterior Codes

Unlike anterior codes (30901/30903), which are unilateral and require modifier -50 for bilateral treatment, posterior codes (30905/30906) are inherently bilateral. Never append modifier -50 to 30905 or 30906. Doing so results in duplicate payment requests and constitutes overcoding.

Rule 6 — Document That Bleeding Is Posterior in Origin

The diagnosis of posterior epistaxis must be documented in the chart. The provider must have evidence — or a clinical assessment — that the bleeding originates posterior to the posterior head of the inferior turbinate and that anterior packing alone is insufficient. Common documentation: “blood noted tracking posteriorly,” “examination revealed posterior pharyngeal blood flow,” “anterior packing failed to control hemorrhage consistent with posterior source,” “nasopharyngoscopy confirmed posterior bleed.” Without posterior origin documentation, 30905 is not defensible on audit — default to anterior complex (30903) if documentation is ambiguous.

Rule 7 — 0-Day Global: Multi-Day Hospital E&M Fully Billable

In the inpatient setting, the treating physician can and should bill daily subsequent hospital care E&M codes (99231-99233) throughout the patient’s stay, even in the same admission where 30905 was billed. The 0-day global period means every calendar day is fully billable. This is not overcoding — it is correct application of the global period rules.

Rule 8 — Endoscope Use Determines 30905 vs. 31238

If any nasal endoscope is used, the coding decision tree is: “Was the endoscope the active treatment instrument, or just a visualization tool?” Visualization only → 30905. Active treatment (cautery delivered through or directly guided by the scope) → 31238. This single determination has a wRVU impact of approximately 1.83 units (~$59 facility). Query the provider if the operative note is ambiguous.

Anesthesia Considerations

CPT 30905 does not require general or MAC anesthesia in standard practice. The procedure is performed with:

Topical vasoconstrictor/anesthetic — oxymetazoline or cocaine 4% on pledgets to the nasal cavity prior to packing
Local anesthetic injection — pterygopalatine fossa block or greater palatine nerve block may be used in selected patients for posterior cautery
Procedural sedation — used in some ED settings for anxious or uncooperative patients; this is a separate service from 30905 and is billed by the administering provider under 99151-99153 or similar codes
For endoscopic posterior cautery (31238), the procedure may be performed under general anesthesia in the OR or under topical/local anesthesia in a procedure room depending on patient factors and setting

Note

If general or MAC anesthesia is required, the anesthesiologist bills separately under CPT 00160 (anesthesia for procedures on nose and accessory sinuses) or 00162 (radical surgery). This does not change 30905.

Coding Examples

Example 1 — Classic Posterior Packing in the Emergency Department, Initial

A 78-year-old male on warfarin presents to the ED with heavy right-sided nosebleed for 90 minutes that did not respond to anterior digital pressure or anterior gauze packing placed by triage. INR is 3.4. ENT is consulted. Nasopharyngoscopy confirms active posterior bleeding. A double-balloon epistaxis catheter (Epistat) is placed transnasally, posterior balloon inflated to 10 mL, anterior balloon inflated to 40 mL. Bleeding controlled. Patient is admitted for monitoring and INR reversal.

CPT: 30905 — Control nasal hemorrhage, posterior, initial ICD-10-CM (Principal): R04.0 — Epistaxis ICD-10-CM (Secondary): T45.515A — Adverse effect of anticoagulants, initial encounter ICD-10-CM (Secondary): Z79.01 — Long-term use of anticoagulants ICD-10-CM (Secondary):I48.11 — Longstanding persistent atrial fibrillation (underlying reason for warfarin) POA: R04.0 = Y; T45.515A = Y; I48.11 = Y Note: The INR elevation and anticoagulation should be documented and coded to support CC-level secondary diagnosis (T45.515A = CC) and accurate DRG assignment

Example 2 — Anterior Packing Attempted Then Posterior Placed Same Session

A 65-year-old female presents to an urgent care with posterior pharyngeal blood. The treating physician first places anterior bilateral Merocel sponge packs, but blood continues to track posteriorly. A Foley catheter (14 Fr) is then inserted transnasally into the nasopharynx, balloon inflated to 8 mL, secured anteriorly.

CPT: 30905 only — Do NOT also bill 30901, 30903, or both; the anterior packing attempt is bundled into 30905 ICD-10-CM: R04.0 — Epistaxis ICD-10-CM: I10 — Essential hypertension (if documented as comorbidity) Note: NCCI bundles anterior epistaxis codes into 30905 — reporting 30903 + 30905 together is a compliance violation

Example 3 — Initial Packing Day 1, Rebleed Day 2, Rebleed Day 3 (Inpatient)

A 72-year-old male with HHT (Osler-Weber-Rendu) is admitted with posterior epistaxis.

Day	Event	CPT	Notes
Day 1 AM	Initial posterior pack placed (Epistat)	30905	Initial treatment
Day 1 PM	Subsequent hospital E&M	99232	0-day global — fully billable
Day 2	Pack displaced; repositioned	30906	Subsequent — different from initial
Day 2	Subsequent hospital E&M	99232	Fully billable
Day 3	Pack removed; rebleed; new pack placed	30906	Subsequent again
Day 3	Subsequent hospital E&M	99232	Fully billable

ICD-10-CM (Principal): R04.0 — Epistaxis ICD-10-CM (Secondary): I78.0 — Hereditary hemorrhagic telangiectasia Compliance note: Each 30906 on days 2 and 3 is separately billable with no modifier needed (0-day global). Each day’s E&M is separately billable. This is appropriate multi-visit billing, not overcoding.

Example 4 — Posterior Epistaxis Escalated to TESPAL (Two-Session Scenario)

A 68-year-old male presents to the ED on Monday with severe posterior epistaxis. Initial posterior packing is placed (30905). He is admitted. The packing continues to fail over 48 hours. On Wednesday, he is taken to the OR for endoscopic sphenopalatine artery ligation bilaterally (TESPAL, 31241). Pack is removed in the OR.

Day 1 (ED): 30905 — Initial posterior packing Day 2 (Hospital): 99232 — Subsequent inpatient E&M Day 3 (OR): 31241 — Transnasal endoscopic SPA ligation (30905 is NOT rebilled on Day 3 — it was placed 2 days prior; the OR encounter is separately billed as the TESPAL session) ICD-10-CM (both claims): R04.0 — Epistaxis ICD-10-CM (Secondary): I16.0 — Hypertensive urgency (if documented)

Example 5 — E&M + 30905 Same Day with Modifier -25

A patient presents to the ENT clinic with heavy posterior nosebleed. The physician performs a comprehensive established patient visit — reviews medical history, documents oral anticoagulation, blood pressure 190/110, evaluates severity — and then performs posterior packing with a Foley catheter.

CPT: 99215-25 — High-complexity E&M, established patient, with modifier -25 CPT: 30905 — Posterior epistaxis control, initial ICD-10-CM: R04.0 — Epistaxis ICD-10-CM: I16.0 — Hypertensive urgency ICD-10-CM: T45.515A — Adverse effect anticoagulants (if anticoagulant is the contributing factor) Key: Modifier -25 on the E&M is mandatory; without it, the E&M will deny as part of the procedure fee

Example 6 — Posterior Epistaxis Secondary to Hematologic Malignancy

A 58-year-old woman with acute myelogenous leukemia (AML) and severe thrombocytopenia (platelet count 12,000) is admitted with posterior nasal hemorrhage. ENT places bilateral posterior packs.

CPT: 30905 — Posterior epistaxis control, initial ICD-10-CM (Principal): C92.00 — Acute myeloid leukemia, not having achieved remission (drives admission — the leukemia and thrombocytopenia are the reason for the hemorrhagic episode) ICD-10-CM (Secondary): R04.0 — Epistaxis ICD-10-CM (Secondary): D69.6 — Thrombocytopenia, unspecified (or D69.3 if ITP component) MS-DRG: Governed by C92.00 as principal → MDC 17 (Myeloproliferative Diseases and Poorly Differentiated Neoplasms) — significantly higher relative weight than MDC 03 Note: Sequencing the leukemia as principal (not the epistaxis) is critical for accurate DRG assignment and appropriate risk-adjustment capture

Example 7 — Posterior Epistaxis from Nasopharyngeal Carcinoma

A 52-year-old male with known nasopharyngeal carcinoma presents with posterior epistaxis. Posterior packing is placed in the ED. He is admitted for hemostasis and oncology evaluation.

CPT: 30905 — Posterior epistaxis control, initial ICD-10-CM (Principal): C11.9 — Malignant neoplasm of nasopharynx, unspecified (or specify by subsite per documentation) ICD-10-CM (Secondary): R04.0 — Epistaxis MS-DRG: 146/147/148 — ENT malignancy DRGs (MDC 03) HCC: C11.9 carries HCC weight; ensures risk-adjusted reimbursement reflects true clinical complexity

Differential Coding Summary

Clinical Scenario	Correct Code
Posterior epistaxis, first treatment (packing or cautery)	30905
Posterior epistaxis, repeat treatment (packing failed or rebled)	30906
Anterior epistaxis, simple, first treatment	30901
Anterior epistaxis, complex, first treatment	30903
Anterior AND posterior packing, same session	30905 only (anterior bundled)
Endoscopic active cautery of posterior vessel (scope = treatment instrument)	31238
Endoscopic SPA ligation	31241
Open/transantral internal maxillary artery ligation	30920
Interventional radiology embolization	61626
Packing placement AND separate, documented E&M same day	30905 + E&M-25
Multi-day inpatient packing (subsequent days)	30906 each new packing episode + daily E&M
Posterior packing + modifier -50	Incorrect — do not use -50 with posterior codes
No pack/cautery left in place; bleeding stopped spontaneously	E&M only (99213-99215)

Quick Reference Summary

Field	Detail
Code	30905
Type	CPT Procedure Code
Full Descriptor	Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial
Setting	ED, Hospital Inpatient, HOPD, rarely office
Anesthesia	Topical/local; no general anesthesia required standard
Global Period	0 days — all codes in epistaxis family are 0-day global
wRVU	~3.01 (facility)
HCC	No (procedure code); underlying diagnoses may be HCC
Assistant Payable	No — Medicare indicator 0
Bilateral Modifier	NO — 30905 is inherently bilateral; never use modifier -50
vs. 30906	30905 = first posterior treatment; 30906 = all subsequent treatments (note: 30906 has higher wRVU ~3.88)
vs. 31238	30905 = packing or cautery by any method; 31238 = endoscope is active treatment instrument
vs. 31241 (TESPAL)	30905 = conservative packing; 31241 = endoscopic SPA ligation in OR
NCCI Bundle	30901 and 30903 are BUNDLED into 30905; do not report anterior codes with 30905
Multi-Day Billing	0-day global = each day’s packing (30906) and E&M separately billable — major revenue opportunity in inpatient setting
Must Document	Posterior origin of bleed (blood tracking posteriorly, pharyngeal blood, anterior packing failure)
Common Errors	Appending -50; billing 30901 or 30903 + 30905 together; not billing daily inpatient E&M; not appending -25 to same-day E&M; calling subsequent packing 30905 instead of 30906

Explorer

30905

👩🏾‍⚕️ CPT Code 30905 — Control of Posterior Nasal Hemorrhage, Initial

Official Full Descriptor

Code Classification & Position in the CPT Hierarchy

Full Epistaxis Control Code Family — Complete Reference

Escalation Procedures — Separately Reportable When 30905 Fails

Procedure Description — What CPT 30905 Represents

Clinical Definition

Anatomy — Posterior vs. Anterior Epistaxis

The Posterior Nasal Space: Anatomical Boundaries of Packing

Methods — “Any Method” Under 30905

Includes

Excludes / Do Not Report Together

NCCI Bundles — Critical Rules for 30905

30905 vs. 31238 — The Endoscope Decision Point

30905 vs. 31241 (TESPAL — Transnasal Endoscopic Sphenopalatine Artery Ligation)

Do Not Append Modifier -50 to 30905

Additional Codes That Should NOT Be Reported with 30905

HCC (Hierarchical Condition Category)

wRVU (Work Relative Value Units)

Assistant Payable

Global Period — 0 Days

What 0-Day Global Period Means for Posterior Epistaxis

Multi-Day Inpatient Packing Scenario

Site of Service (SOS)

MS-DRG Assignment

Primary DRG Family — MDC 03 (Ear, Nose, Mouth and Throat)

When Posterior Epistaxis Groups to Higher DRGs

DRG Shift When Etiology Governs Principal Diagnosis

CC/MCC Status of Secondary Diagnoses Paired with 30905

Commonly Paired ICD-10-CM Diagnosis Codes

Primary Diagnosis

Systemic/Vascular Causes

Coagulopathy

Medication-Related — Adverse Effect Coding

Nasal/Sinus Structural Causes

Malignancy-Related

Trauma

Modifier Considerations for CPT 30905

Packing Removal — Is It Separately Billable?

Relationship to 31241 — TESPAL (Transnasal Endoscopic Sphenopalatine Artery Ligation)

Coding Guidelines, Rules & Common Errors

Rule 1 — Anterior + Posterior Same Session = 30905 Only

Rule 2 — Initial vs. Subsequent: Date of Service Governs

Rule 3 — “Initial” Does Not Reset for Readmission

Rule 4 — Same-Day E&M Requires Modifier -25

Rule 5 — No Modifier -50 for Posterior Codes

Rule 6 — Document That Bleeding Is Posterior in Origin

Rule 7 — 0-Day Global: Multi-Day Hospital E&M Fully Billable

Rule 8 — Endoscope Use Determines 30905 vs. 31238

Anesthesia Considerations

Coding Examples

Example 1 — Classic Posterior Packing in the Emergency Department, Initial

Example 2 — Anterior Packing Attempted Then Posterior Placed Same Session

Example 3 — Initial Packing Day 1, Rebleed Day 2, Rebleed Day 3 (Inpatient)

Example 4 — Posterior Epistaxis Escalated to TESPAL (Two-Session Scenario)

Example 5 — E&M + 30905 Same Day with Modifier -25

Example 6 — Posterior Epistaxis Secondary to Hematologic Malignancy

Example 7 — Posterior Epistaxis from Nasopharyngeal Carcinoma

Differential Coding Summary

Quick Reference Summary

Graph View

Table of Contents

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