ED Coding and Reimbursement Alert

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Question: We are wondering how to code for a fecal disimpaction encounter. The doctor performed the disimpaction on an elderly patient after administering a moderate sedative. ED notes suggest a level-four E/M service. How should we report the encounter, and is there a way to report the sedation separately from the E/M service?

Minnesota Subscriber

Answer: While there is a code for fecal disimpaction in CPT 2006, its definition specifies -under anesthesia,- which the AMA has said requires performance in a formal OR setting. 
 
You are probably best served depending on the carrier to report a moderate sedation code and an E/M code when reporting this fecal disimpaction scenario.
 
On the claim:
 
- for the E/M service, report 99284 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: a detailed history; a detailed examination; and medical decision-making of moderate complexity).
 
- for the sedation, report 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).
 
- attach ICD-9 code 560.39 (Impaction of intestine; other) to the claim as well as any other diagnoses the patient may have.

Another option: There could be another way to report this encounter.
 
- report 45915 (Removal of fecal impaction or foreign body [separate procedure] under anesthesia) for the fecal disimpaction.
 
- attach modifier 52 (Reduced services) to 45915 to show that you are billing for moderate sedation, not full sedation.
 
- attach ICD-9 code 560.39 to 45915 to prove medical necessity for the disimpaction.

Caveat: The descriptor for 45915 states -under
anesthesia,- and the AMA states that a patient is not -under anesthesia- unless he is in the OR. Before reporting 45915-52, ask the insurer if the claim is acceptable.
 
Most compliance experts will feel more comfortable with bundling the fecal impaction into the E/M if the service was not provided in an operative setting, since there have been adverse rulings in the past on inappropriate use of modifier 52.

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