Anesthesia Coding Alert

Question: A 34-year-old patient with a dislocated left shoulder reported to the outpatient clinic. The physician sedated the patient to the point that he was relaxed but still conscious. Then the physician manipulated the shoulder back into place. What sedation code should I report?

Connecticut Subscriber

Answer: If the same physician performs the sedation and the procedure, you may be able to account for the sedation by reporting 99144 (Moderate sedation services [other than those services described by codes 00100-01999] provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; age 5 years or older, first 30 minutes intra-service time). Include 23650 (Closed treatment of shoulder dislocation, with manipulation; without anesthesia) for the reduction service.

Tips on 99144: Code 99144 refers to the first 30 minutes of intra-service sedation by the same physician performing the diagnostic or therapeutic service that the sedation supports. In this procedure, an independent trained observer must be present to assist in the monitoring of the patient’s level of consciousness and physiological status. The patient should be 5 years or older.