Gastroenterology Coding Alert

Question: The gastroenterologist meets an 83-year-old established hospice patient at the hospital. A hospice caretaker says the patient has not defecated in four days, and the patient reports he has had pain nonstop for the past 12 hours. The gastroenterologist takes a detailed history and during a detailed exam, she diagnoses fecal impaction. The physician performs sedation with Versed and disimpaction; there was a qualified observer overseeing the sedation. The physician then counsels the caretaker on caring for the patient and recommends a follow-up visit with the patient's primary care physician within two weeks. I reported 45915 for the disimpaction and got a denial. What happened?

Alaska Subscriber

Answer: You should have coded the disimpaction differently. When you re-submit the claim, report the following:

• 99143 (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; younger than 5 years of age, first 30 minutes intra-service time) for the sedation.

• the appropriate-level hospital care E/M code based on the notes; most likely 99221 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision-making that is straightforward or of low complexity ...)

• 560.39 (Impaction of intestine; other) appended to 99143 and 99221 to represent the patient's condition.

Explanation: The 45915 (Removal of fecal impaction or foreign body [separate procedure] under anesthesia) code requires the patient be "under anesthesia," which typically means general anesthesia, not moderate sedation. Just about all 45915 services occur in the OR under surgical guidance.