ED Coding and Reimbursement Alert

Question: A 2-year-old patient reports to the ED. The father says the baby has not defecated in four days, and has been crying almost nonstop for the past 12 hours. The physician takes a detailed history and during a detailed exam, the physician diagnoses fecal impaction. The physician performs sedation with Versed and performs disimpaction; she then counsels the father on caring for the child and recommends a follow-up visit with the child's primary care physician within two weeks. I reported 45915 for the dismpaction and got a denial. What happened?

Ohio Subscriber

Answer: You should have coded the disimpaction differently. When you re-submit the claim, report the following:

• 99143 (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; younger than 5 years of age, first 30 minutes intra-service time) for the sedation

• the appropriate-level ED E/M code based on the notes; most likely 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of moderate complexity ...)

• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99284 to show that it was a separate service from the sedation

• 560.39 (Impaction of intestine; other) appended to 99143 and the E/M to represent the patient's condition.

Explanation: Code 45915 (Removal of fecal impaction or foreign body [separate procedure] under anesthesia) requires the patient be "under anesthesia," which typically means general anesthesia, not moderate sedation. Just about all 45915 services occur in the OR, not the ED.