Only a Conscious Sedation Is Separately Reportable

Only a Conscious Sedation Is Separately Reportable

Recently, our surgeon carried out an emergency room consult and administered intravenous sedation to carry out an incision and drainage of a perirectal abscess. If I charge for the consult and the procedure, can you also code for the IV sedation?

Well, you can report an intravenous (IV) sedation in addition to an evaluation & management and procedure under certain circumstances. Only a conscious sedation is separately reportable, and that is so in some case only.

If your surgeon carried out conscious sedation, you may be able to bill that with the right documentation and depending on precisely which O&D code you are using. Remember that any code that has the 'target' symbol in CPT covers conscious sedation, meaning that you cannot bill the service separately.

If the IV sedation you talked about was conscious sedation for an allowable procedure such as 45005 (Incision and drainage of submucosal abscess, rectum), you'll need to document who was monitoring the patient during the case (name and credentials such as John Doe, RN). You will also need to document what drug was used and how much as well as the vitals of the patient before, during and after the sedation. If you do not have that documentation, you cannot bill for the conscious sedation.

Other IVs are out: If you cannot bill conscious sedation, you are out of luck for the IV. Beginning an IV is a facility service in the emergency department; as such you cannot bill for starting the IV separately.

For more on this, sign up for a one-stop medical coding guide like Supercoder.

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