tci ED Coding & Reimbursement Alert - 2009 Issue 4

You Be the Coder: Moderate Sedation and Fracture Care

Question: A patient reports to the ED with a badly injured right foot; he was using a snow plow to clear his driveway, and the plow overturned and fell on his lower body. The physician takes x-rays that confirm a closed navicular fracture with some bones out of alignment. Notes indicate a level-three E/M, and also a high level of patient pain and anxiety. To calm the patient, the physician provides 19 minutes of moderate sedation while she resets the foot and puts it in a plaster cast. There is a nurse on hand during the sedation to monitor...

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