tci General Surgery Coding Alert - 2008 Issue 9

Reader Questions: Zoom In on 'Targets' Before Coding Sedation

Question: An established 64-year-old patient complaining of rectal pain and abdominal cramps reports to the surgeon. During a level-four E/M service, the surgeon discovers a foreign body (FB) in the colon. The surgeon then removes the FB via flexible sigmoidoscopy. Due to the patient's anxiety and pain, the surgeon provides 26 minutes of moderate sedation during the procedure. Can we report the sedation separately? Massachusetts SubscriberAnswer: You cannot report moderate sedation separately in this case. CPT bundles moderate sedation into all of the colonoscopy codes, so your claim cannot include 99144 (Moderate sedation services [other than those services described...

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