ED Coding and Reimbursement Alert

Question: An adult patient with pain in his upper chest and right shoulder reports to the ED. During a level-three E/M, the physician diagnoses a sternoclavicular dislocation. Due to the patient's pain, the physician provides sedation (Versed) while a nurse monitors the process and reduces the dislocation with closed treatment and manipulation. The patient's consciousness was depressed, but he still responded to verbal commands. Can I report the sedation separately?

West Virginia Subscriber

Answer: Unless the insurance company instructs you otherwise, you should definitely report the sedation, in addition to coding for E/M and reduction. According to your description, the physician provided the patient with moderate sedation.

Definition: "Moderate sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation," according to Medicare. When your physician provides this type of sedation and performs the procedure, choose a code from the 99143-99145 set to represent the service.

If your physician's sedation does not meet the above rules, do not code the sedation separately. Payment from carriers should be forthcoming.

"Physicians who both perform, and provide moderate sedation for, medical/surgical services will be paid for the conscious sedation consistent with CPT guidelines," according to MLM Matters transmittal MM5618. On the claim, report the following:

- 23525 (Closed treatment of sternoclavicular dislocation; with manipulation) for the dislocation treatment

- 839.61 (Other, multiple, and ill-defined dislocations; other location, closed; sternum) linked to 23525 to represent the dislocation

- 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) for the sedation

- 839.61 linked to 99144 to represent the dislocation

- 99283 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and medical decision-making of moderate complexity) for the E/M service

- modifier 25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) linked to 99283 to show that the dislocation treatment and E/M were separate services

- 786.59 (Other chest pain) and 719.41 (Pain in joint; shoulder region) linked to 99283 to prove medical necessity for the E/M.

Of note: There are codes for one physician providing moderate sedation in support of his own procedure (99143-99145), and different codes for moderate sedation provided by a physician other than the one performing the procedure (99148-99150).

The 99143-99145 category of moderate sedation codes requires the presence of "an independent trained observer to assist in monitoring the patient's level of consciousness and physiological status." Typically that would be a nurse.