ED Coding and Reimbursement Alert

You Be the Coder:

Choose E/M for Fecal Disimpaction

Question: The ED physician performed a manual fecal disimpaction after administering IV MS and Diazepam. I was going to report 45915, but the -under anesthesia- part leaves me stumped. Should I bill this code, or are there other options I should consider?


South Carolina Subscriber


Answer: One approach you could use would be to append modifier 52 (Reduced services) to 45915 (Removal of fecal impaction or foreign body [separate procedure] under anesthesia), but the American Medical Association's (AMA) CPT department has stated that the -under anesthesia- term represents work performed in an operating room.

Instead, you may want to favor the more conservative option of rolling the work of
parenteral narcotics administration into the E/M code and capturing -high- risk in the risk table, thus allowing the E/M code you choose to reflect the physician's extra work.

Other Articles in this issue of

ED Coding and Reimbursement Alert

View All

Which Codify by AAPC tool is right for you?

Call 844-334-2816 to speak with a Codify by AAPC specialist now.