ED Coding and Reimbursement Alert

Question: A patient reports to the ED with a badly injured right foot; he was using a snow plow to clear his driveway, and the plow overturned and fell on his lower body. The physician takes x-rays that confirm a closed navicular fracture with some bones out of alignment. Notes indicate a level-three E/M, and also a high level of patient pain and anxiety. To calm the patient, the physician provides 19 minutes of moderate sedation while she resets the foot and puts it in a plaster cast. There is a nurse on hand during the sedation to monitor the patient's status. Can we report the sedation?

Pennsylvania Subscriber

Answer: You should be able to report the moderate sedation separately, provided the documentation clearly indicates the presence and role of the nurse during the encounter.

Don't forget this documentation: an "independent observer" is required for moderate sedation coding).

On the claim, report the following:

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

- modifier 54 (Surgical care only) appended to 28455 to show that you are only coding for the initial fracture 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

- 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity ...) for the E/M

- modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) appended to 99283 to show that the E/M and fracture care were separate services

- E820.0 (Nontraffic accident involving motor-driven snow vehicle; driver of motor vehicle other than motorcycle) appended to 28475, 99144, and 99283 to represent the cause of the patient's injury

- 825.22 (Fracture of other tarsal and metatarsal bones, closed; navicular [scaphoid], foot) appended to 28455, 99144, and 99283 to represent the patient's fracture.