Orthopedic Coding Alert

Question: Our orthopedic surgeons perform many manipulations of dislocated total hip replacements (27265). Most of the time these are done in the emergency department (ED) with the physician using IV sedation. The sedative is usually administered by the ED nurse and monitored by the orthopedist. My physicians feel they should receive some type of reimbursement for the added responsibility of the sedation. Is it possible for me to bill for this monitoring using 90780 in addition to the 27265?

Alaska Subscriber

Answer: The AAOS Complete Global Service Data Guide for Orthopedic Surgery indicates that local infiltration of medication, anesthetic or contrast agent is bundled with 27265 (closed treatment of posthip arthroplasty dislocation; without anesthesia). It even specifies 90780 (IV infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour). Virtually the only time a physician can charge for conscious sedation codes is when he or she dictates that monitoring the sedation was the service provided.

All other uses of conscious sedation, regardless of setting, are included in the global package for the procedure. According to HCFAs Global Surgery Policy, additional surgical services during the 90-day global postoperative period for complications of the original surgery that do not require a return trip to the operating room are not reimbursable. Therefore, when a patient dislocates while in global, reductions done in the ED should not be billed to Medicare.