ED Coding and Reimbursement Alert

Question: A 14-year-old patient reports to the ED with an injured right shoulder. While she was rock climbing, a hand hold broke loose, causing her to fall. She landed on the right shoulder. After a level-three E/M service, the physician diagnoses a dislocated shoulder. The ED physician performs closed treatment of the dislocation, during which he orders versed sedation and is face to face at the bedside for 26 minutes of sedation time. After the procedure, the ED physician discharges the patient into her mother’s care with instructions to follow up with the orthopedist in 48 hours for further care and a recheck. Is the moderate (conscious) sedation bundled into the treatment in this scenario?

Arkansas Subscriber

Answer: Provided there was an independent observer there during the versed sedation, you can report the sedation and the shoulder repair separately. On the claim, report the following:

23650 (Closed treatment of shoulder dislocation, with manipulation; without anesthesia) for the shoulder treatment

Modifier 54 (Surgical care only) appended to 23650 to show that you are coding only for the surgical care if the orthopedist is doing the follow up

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 

99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity …) for the E/M

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 show that the E/M was separate from the shoulder reduction and sedation

831.00 (Closed dislocation, shoulder, unspecified) appended to 23650, 99144, and 99284 to represent the patient’s injury  For ICD-10, report code S43.006A (Unspecified dislocation of unspecified shoulder joint, initial encounter)