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General Surgery Coding Alert

Reader Questions:

Separate IV Charge Might Not Fly

Published on Tue Jan 18, 2011

Question: Our surgeon recently did an emergency room consult and administered intravenous sedation to perform an incision and drainage of a perirectal abscess. If I charge for the consult and the procedure, can I also code for the IV sedation? Answer: You can only report an intravenous (IV) sedation in addition to an E/M and procedure under certain circumstances. Only a conscious sedation is separately reportable, and even that's only in some cases. If your surgeon performed conscious sedation, you may be able to bill that with the proper documentation and depending on exactly which I&D code you're using. Note than any code that has the "target" symbol in CPT includes conscious sedation, which means that you can't separately bill the service. If the IV sedation you mentioned was conscious sedation for an allowable procedure, such as 45005 (Incision and drainage of submucosal abscess, rectum), you will need to document [...]
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