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ED Coding and Reimbursement Alert

You Be the Coder:

Moderate Sedation and the Separation Repair

Published on Fri Mar 26, 2010

Question: A 14-year-old patient reports to the ED with an injured right shoulder. While she was hiking, a small rockslide knocked her down, and she landed on the 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 with the patient 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 re-check. 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; [...]
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