ED Coding and Reimbursement Alert

Question: A patient reports to the ED with a badly injured right foot; he was using a snow plow to clear his driveway, and the plow overturned and fell on his lower body. The physician takes x-rays that confirm a closed navicular fracture with some bones out of alignment. Notes indicate a level-three E/M, and also a high level of patient pain and anxiety. To calm the patient, the physician provides 19 minutes of moderate sedation while she resets the foot and puts it in a plaster cast. There is a nurse on hand during the sedation to monitor the patient's status. Can we report the sedation? Pennsylvania Subscriber Answer: You should be able to report the moderate sedation separately, provided the documentation clearly indicates the presence and role of the nurse during the encounter. Don't forget this documentation: an "independent observer" is required for moderate sedation coding). On the [...]