ED Coding and Reimbursement Alert

Question: After a level-five E/M service, the ED physician inserts a chest tube in a patient with traumatic hemothorax (there was no mention of open wound in the notes). Due to the patient's anxiety and pain, the physician and staff provide 26 minutes of moderate sedation during the procedure. Can we report the sedation separately?

Massachusetts Subscriber

Answer: You cannot report the moderate sedation separately in this instance. Moderate sedation is bundled into the chest tube insertion code, so your claim cannot include 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).

How can you tell? It's easy to check if moderate sedation is bundled into a procedure code -- simply look up the code in your CPT book. If the code has a black target symbol 8 next to it, you cannot report moderate sedation in addition to that code. The code for chest tube insertion, 32551, has such a mark next to it. (CPT 2008's Appendix G lists all of the procedure codes that include moderate sedation.)

So on the claim, you should report the following:

- 32551 (Tube thoracostomy, includes water seal [e.g., for abscess, hemothorax, empyema], when performed [separate procedure]) for the chest tube insertion

- 99285 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: a comprehensive history; a comprehensive examination; medical decision-making of high complexity) for the E/M

- modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) linked to 99285 to show that the E/M and tube insertion were separate services

- 860.2 (Traumatic pneumothorax and hemothorax; hemothorax without mention of open wound into thorax) linked to 32551 and 99285 to represent the hemothorax.