ED Coding and Reimbursement Alert

Question: A 17-year-old patient reports to the ED with an injured lower left leg. The ED physician orders x-rays, which confirm a scaphoid fracture; notes indicate the bone fragments were not aligned or in proper position. The patient reports extreme pain during the exam, and becomes very anxious when he learns of the pending surgery, so the ED physician orders 22 minutes of conscious sedation while performing closed treatment of the fracture. The physician then casts the injury and instructs the patient to report to an orthopedist for follow-up care. Can I report the x-rays and conscious sedation separately?

California Subscriber

Answer: As long as the 22 minutes of sedation time meets the following guidelines, you can code separately for the sedation:

Sedation time officially started with administration of therapeutic agent; there was continuous face-to-face attendance between patient and physician (or other qualified provider) during the sedation; the session ended with personal contact between the patient and the physician providing the sedation.

So if the sedation portion of the session met the above requirements, you should report the following:

- 28455 (Treatment of tarsal bone fracture [except talus and calcaneus]; with manipulation, each) for the fracture care

- modifier 54 (Surgical care only) appended to 28455 to show that you are only coding for the procedure, not the follow-up care

- 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

- 825.22 (Fracture of other tarsal and metatarsal bones, closed; navicular [scaphoid], foot) appended to 28455 and 99149 to represent the patient's injury.

In addition: Report any independent and contemporaneously read x-rays. Also, don't forget to include an E/M code for this patient as well. In your scenario, the ED physician almost certainly performed an E/M prior to the fracture care. Technically, you should append modifier 57 (Decision for surgery) to the E/M, since the treatment is a "surgery."

Some payers, however, may prefer 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 the E/M code. If you-re unsure, check with the insurer before filing.