23625 vs 23655?

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laurabee

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Please help. The doctor and I have different ideas about the code that should be used. Here is the op report:

PREOPERATIVE DX: Fracture-dislocation left shoulder. Anterior dislocation with greater tuberosity fracture.

POSTOPERATIVE DX: Same

PROCEDURE: Closed reduction and application of shoulder immobilizer.

PROCEDURE IN DETAIL: Conscious sedation was performed. Manipulative closed reduction was initially performed. There was some question whether it was reduced and an x-ray taken and it had not been reduced. So he was given some more medication and manipulated with axial traction in line with the deformity with a sheet on the patient's torso and a sheet on the patient's elbow, and just held in longitudinal traction until it fatigued in slight rotation and the shoulder did reduce without any significant trauma. He had good radial pulse at the end of the procedure. He was placed in a shoulder immobilizer. AP and transcapular views showed good reduction of the humeral head in the glenoid.

??
 
my vote is for 23625. conscious sedation is conscious sedation, not anesthesia.
which code did you want & which did the doc want?
{that's my opinion on the posted matter}
 
I coded as 23625 and the doc thinks it could also be 23655 and wanted to know which was better. I thought I'd get a second opinion just to make sure I'm correct before committing to anything!
 
I think that the 23655 better describes the procedure performed.

Assumingly (because its not documented) the patient was probably given either Versed or Fentynal both which are anesthesia agents. The code 23655states anesthesia, it does not state "general anesthesia".

thanks
Mary
 
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