ED Coding and Reimbursement Alert

Question: An elderly man presented to our ED last week with a dislocation of the patella. He was in a great deal of pain and the physician was forced to administer intravenous Dilaudid and Valium in order to treat him. Would we assign a code that includes anesthesia (i.e., 27562) for this? Colorado Subscriber Answer: No, that would not be appropriate. Instead, if the documentation is in place and appropriate the practice could report moderate sedation 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). Typically, CPT® has indicated that codes including the language "with anesthesia" or "requiring anesthesia," as [...]