tci ED Coding & Reimbursement Alert - 2015 Issue 7
You Be the Coder: Check Sedation Level Achieved Before Assigning A Fecal Disimpaction Code
Question: We are wondering how to code for this fecal disimpaction encounter. The doctor performed the disimpaction on an elderly patient after administering a moderate sedative. ED notes suggest a level 4 E/M service. How should we report the encounter, and is there a way to report the sedation separately from the evaluation and management (E/M) service? Minnesota Subscriber Answer: While there is a code for fecal disimpaction in CPT® 2015, its definition specifies “under anesthesia” which the AMA has taken the position requires performance in a formal OR setting. Depending on the payer, you...
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