ED Coding and Reimbursement Alert

Question: An elderly man presented to our ED last week with a dislocation of the patella. He was in a great deal of pain and the physician was forced to administer intravenous Dilaudid and Valium in order to treat him. Would we assign a code that includes anesthesia (i.e., 27562) for this?

Colorado Subscriber

Answer: No, that would not be appropriate. Instead, if the documentation is in place and appropriate the practice could report moderate sedation 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).

Typically, CPT® has indicated that codes including the language "with anesthesia" or "requiring anesthesia," as 27562 (Closed treatment of patellar dislocation; requiring anesthesia) does almost always refer to general anesthesia or a formal trip to the operating room. These cases are often treated in a surgical suite, with an anesthesiologist providing the anesthesia services. If this occurs, the surgeon would report the procedure code (e.g. 27562) and the anesthesiologist would report the appropriate code from the anesthesia section of CPT®.

When medications like Dilaudid and Valium are used, they are most likely administered for sedation or simply pain control, rather than true anesthetic effects. They are categorized as conscious sedation agents and typically allow the patient to be awake, aware of his surroundings and able to communicate during a procedure. ED physicians may also use conscious sedation when they need the patient to be extremely still during specific procedures like suturing lacerations.

Therefore, in this case, it would be more appropriate to assign 27560 (Closed treatment of patellar dislocation; without anesthesia), along with one of the codes CPT® provides to describe the administration of conscious sedation (99143-99150). Be careful to choose the correct moderate sedation code describing that the same physician who provides the treatment administers the sedation (99143-99145). If another physician provides the conscious sedation, the appropriate moderate sedation code (99149-99150) should be assigned.

Medicare and some other payers do not commonly reimburse 99143 and 99145.