tci ED Coding & Reimbursement Alert - 2008 Issue 3

Reader Questions: Meet 'Moderate' Guidelines for Sedation Coding

Question: An adult patient with pain in his upper chest and right shoulder reports to the ED. During a level-three E/M, the physician diagnoses a sternoclavicular dislocation. Due to the patient's pain, the physician provides sedation (Versed) while a nurse monitors the process and reduces the dislocation with closed treatment and manipulation. The patient's consciousness was depressed, but he still responded to verbal commands. Can I report the sedation separately? West Virginia Subscriber Answer: Unless the insurance company instructs you otherwise, you should definitely report the sedation, in addition to coding for E/M and reduction. According to your description...

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