ED Coding and Reimbursement Alert

Question: I submitted a claim for a shoulder dislocation using codes 23650 (Closed treatment of shoulder dislocation, with manipulation; without anesthesia) appended with modifier -54 (Surgical care only) and 99141 (Sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation). The denied claim's EOB states that shoulder dislocation fees include conscious sedation. But other insurers have not denied these claims. What should I do?

North Carolina Subscriber

Answer: You should consult your practice's contract with the carrier. Check the coding set that was mutually agreed upon to make sure your carrier's denial passes muster.

The "included service" note on the EOB indicates one of two things: Either the carrier doesn't recognize the code, or the carrier has an additional edit that bundles it with other codes. For example, your carrier may bundle conscious sedation with this particular orthopedic procedure. Make sure this bundling falls under contract stipulations. Many carriers have edits that don't recognize certain codes. Some managed-care carriers commonly deny claims coded 99141.

Submitting a hard copy of medical notes that convey the additional work and complexity involved in the patient's care can also sometimes do the trick. Again, check your practice's contract with the carrier to figure out the rules they have for conscious sedation.