General Surgery Coding Alert

Question: Our surgeon recently did an emergency room consult and administered intravenous sedation to perform an incision and drainage of a perirectal abscess. If I charge for the consult and the procedure, can I also code for the IV sedation?

Answer: You can only report an intravenous (IV) sedation in addition to an E/M and procedure under certain circumstances. Only a conscious sedation is separately reportable, and even that's only in some cases.

If your surgeon performed conscious sedation, you may be able to bill that with the proper documentation and depending on exactly which I&D code you're using. Note than any code that has the "target" symbol in CPT includes conscious sedation, which means that you can't separately bill the service.

If the IV sedation you mentioned was conscious sedation for an allowable procedure, such as 45005 (Incision and drainage of submucosal abscess, rectum), you will need to document who was monitoring the patient during the case (name and credentials, such as John Doe, RN). You'll also need to document what drug was used and how much, as well as the patient's vitals before, during, and after the sedation. If you don't have that documentation, you can't bill for the conscious sedation.

Other IVs are out: If you can't bill conscious sedation, you're out of luck for the IV. Starting an IV is a facility service in the emergency department, so you can't separately bill for starting the IV.