ED Coding and Reimbursement Alert

Question: An elderly man presented to our ED with a dislocation of the patella. He was in a lot of pain, and the physician was forced to administer intravenous Dilaudid and Valium to treat him. Should we assign a code that includes anesthesia (i.e., 27562) for this?

Maryland Subscriber

Answer: No, that would not be appropriate. Instead, you should code conscious sedation (99141, Sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation). Typically, CPT indicates that codes including the language "with anesthesia" or "requiring anesthesia," such as 27562 (Closed treatment of patellar dislocation; requiring anesthesia), almost always refer to general anesthesia. These cases are often treated in a surgical suite, with an anesthesiologist providing the anesthesia services. If this occurs, the surgeon would report the procedure code (e.g., 27562), and the anesthesiologist would report the appropriate code from the anesthesia section of CPT.
 
Medications like Dilaudid and Valium are usually administered for pain relief, not for true anesthetic effects. They are categorized as conscious-sedation agents and allow the patient to be awake, aware of his or her surroundings and able to communicate during a procedure. ED physicians may also use conscious sedation when the patient must be still during specific procedures such as suturing lacerations.
 
In this case, it would be more appropriate to assign 27560 (Closed treatment of patellar dislocation; without anesthesia) along with one of the CPT codes used to describe the administration of conscious sedation (99141 and 99142, ... oral, rectal and/or intranasal). One of the requirements of conscious sedation is that the same physician who provides the treatment administers the sedation. If another physician provides the conscious sedation, the appropriate anesthesia code should
be assigned.
 
Medicare and most other payers do not reimburse 99141 and 99142.