ED Coding and Reimbursement Alert

Question: What standard should I follow when claiming fracture care with an E/M code? I realize that pain control is included in fracture care, but what if the physician gives a parenteral-controlled substance? Does that increase the risk as well as the level?

North Dakota Subscriber

Answer: If the physician provides services meeting the definition of conscious sedation, he could bill for that service - as long as the procedure was not included on the list in Appendix G of the 2005 CPT book (see story on front page, "Think Twice Before Billing for ED Ultrasounds," for a partial list of these codes). Otherwise, the pain control is bundled into the procedure.

You are correct to recognize that you should consider the use of controlled substances as part of the medical decision-making portion of the corresponding evaluation and management service. Generally, these are "high- energy" injuries and require a more global assessment of the patient, a service that supports an E/M code (99281-99285) if the physician properly documents it.