ED Coding and Reimbursement Alert

Test your coding knowledge.  Determine how you would code this situation before looking at the box below for the answer.
Question: Our emergency department physician attempted a shoulder reduction while the patient was placed under conscious sedation. The reduction attempt failed, and the patient was sent to x-ray. After the patient returned to the ED, another reduction attempt was made but failed. At this point, there was a shift change and another doctor came on duty. The second physician attempted the reduction for the third time and succeeded. How should I code this? May I report all three attempts at reduction, with a -52 modifier for the unsuccessful tries?

South Carolina Subscriber
      Answer: Many coding experts report that the reduction may be reported three separate times, e.g., 23650, closed treatment of shoulder dislocation, with manipulation; without anesthesia. Modifier -52 (reduced services) would be appended to the code for the first two, unsuccessful attempts. Others view it as simply a prolonged, single attempt.
 
Conscious sedation (99141, sedation with or without analgesia [conscious sedation]; intravenous, intra-muscular or inhalation, or 99142, oral, rectal and/or intranasal) may also be reported (without the modifier) each time, although Medicare will not pay for these services. CPT codes 99141 and 99142 were created to allow for sedation with or without analgesia to be reported by physicians other than anesthesiologists or nurse anesthetists, and are specifically to be used to report conscious sedation when administered by a physician performing the definitive procedure. By definition, 99141 and 99142 require that an independent, trained observer be present to help the physician monitor the patient's physiological status and level of consciousness. The definition of "independent, trained observer" indicates that the designated individual, other than the performing physician, should be responsible for monitoring the patient during the procedures performed with sedation/analgesia. This individual should be able to recognize complications, establish a patient airway and positive-pressure ventilation, and summon additional assistance.  
 
Advanced life-support skills should be immediately available. For instance, an RN observing a patient under conscious sedation and helping the ED physician  monitor the patient's level of consciousness and physiological status during a reduction would be considered an independent, trained observer.
 
If the emergency department physician interpreted the x-rays (e.g., 73030, radiologic examination, shoulder; complete, minimum of two views), he would report this service with modifier -26 (professional component). Of course, correct reporting of this claim will depend in large part on payer policy. Coders should check with the relevant medical director for guidance.