ED Coding and Reimbursement Alert

Question: A 44-year-old patient reports to the ED with an injured left shoulder; a level-four E/M service reveals that the patient has a shoulder dislocation; due to the patient's constant complaints of pain and raised anxiety during the E/M service, the ED physician provides 22 minutes of Fentanyl sedation, during which time he performs closed treatment with manipulation of the dislocated shoulder. There is an independent, licensed observer present to monitor patient status during the procedure.. Can I report the sedation separately in this scenario?

Answer: This procedure is not on the list of codes that cannot be reported in conjunction with moderate sedation services, so you should be safe coding the sedation separately. On the claim, report the following:

• 23650 (Closed treatment of shoulder dislocation, with manipulation; without anesthesia) for the shoulder repair
• 99149 (Moderate sedation services [other than those services described by codes 00100-01999], provided by a physician other than the health care professional performing the diagnostic or therapeutic service that the sedation supports; age 5 years or older, first 30 minutes intraservice time) for the sedation
• 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 ...) for the E/M service
• 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 the E/M, x-rays and fracture treatment were separate services.

Remember: Procedure codes that include moderate sedation in the work units, when performed,feature a "circle with a dot in the middle " symbol next to the code; for example, 32551 (Tube thoracostomy, includes water seal [e.g., for abscess, hemothorax, empyema], when performed [separate procedure]) includes moderate sedation, when performed.