ED Coding and Reimbursement Alert

Question: A 17-year-old patient reports to the ED with an injured lower left leg. The ED physician orders x-rays, which confirm a scaphoid fracture; notes indicate the bone fragments were not aligned or in proper position.

The patient reports extreme pain during the exam, and becomes very anxious when he learns of the pending surgery, so the ED physician performs 22 minutes of moderate sedation while performing closed treatment of the fracture. The physician then casts the injury and instructs the patient to report to an orthopedist for follow-up care. Can I report the x-rays and conscious sedation separately?

California Subscriber

Answer:  You can report moderate sedation -- provided the encounter satisfies the requirements for 99149.

As long as the 22 minutes of sedation time meets the following guidelines, you can code separately for the sedation:

• Sedation time officially started with administration of therapeutic agent.
• There was continuous face-to-face attendance between patient and physician (or other qualified provider) during the sedation.
• The session ended with personal contact between the patient and the ED physician providing the sedation.

So if the sedation portion of the session met the above requirements, you should report the following:

• 28455 (Treatment of tarsal bone fracture [except talus and calcaneus]; with manipulation, each)
• modifier 54 (Surgical care only) appended to 28455 to show that you are only coding for the procedure, not the follow-up care
• 99149 (Moderate sedation services [other than those services described by codes 00100-01999] provided by a physician other than the health care professional performing the diagnostic or therapeutic service that the sedation supports; age 5 years or older, first 30 minutes intra-service time) for the sedation
• 825.22 (Fracture of other tarsal and metatarsal bones, closed; navicular [scaphoid], foot) appended to 28455 and 99149 to represent the patient's injury

In addition you would report any independent and contemporaneously read x-rays. Don't forget your E/M code for this patient as well, which may be as high as 99284 depending on the rest of the documentation. Technically you would append a 57 to the E/M to designate the decision for surgery as 28455 has a 90 day global though payers vary and some may want the 25.