ED Coding and Reimbursement Alert

Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.
Question: An elderly man presented to our ED with a dislocation of the patella. He was in a lot of pain, and the physician administered intravenous Dilaudid and Valium in order to treat him. Should we assign a code that includes anesthesia (e.g., 27562) for this?

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    Answer: No, that would not be appropriate. Instead, you should code conscious sedation (99141, Sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation). CPT has indicated that codes including the language "with anesthesia" or "requiring anesthesia" as 27562 does (Closed treatment of patellar dislocation; requiring anesthesia) usually refer to general anesthesia. These cases are often treated in a surgical suite, with an anesthesiologist providing the anesthesia services. If this occurs, the surgeon should report the procedure code (e.g., 27562), and the anesthesiologist should report the appropriate CPT anesthesia code.
 
Dilaudid and Valium are usually administered for sedation, not for anesthetic effects. They are categorized as conscious-sedation agents and allow the patient to be awake, aware of surroundings and able to communicate during a procedure. ED physicians may also use conscious sedation when the patient needs to be extremely still during specific procedures such as suturing lacerations.

In this case it is more appropriate to assign 27560 (Closed treatment of patellar dislocation; without anesthesia) along with one of the CPT codes that describes the administration of conscious sedation (99141 and 99142, Sedation with or without analgesia [conscious sedation]; oral, rectal and/or intranasal). One of the requirements of conscious sedation is that the physician who provides the treatment also administers the sedation. If another physician provides the conscious sedation, the appropriate anesthesia code should be assigned. Although Medicare and some other payers do not reimburse 99141 and 99142, ED practices should report conscious sedation.
 
Modifier -54 (Surgical care only) should be appended to 27560 if another physician provides the follow-up care. This is often the case because the ED physician would not see the patient on an ongoing basis for this type of injury.