tci ED Coding & Reimbursement Alert - 2015 Issue 10

You Be the Coder: Be Alert For Chart Documentation To Determine The Correct Moderate Sedation Code

Question: HPI A 12 y.o. female presents to the ED via EMS complaining of fall and arm injury. The patient reports being at cheerleading practice this evening when she fell forward from the top of a 2-person-high pyramid. She landed on her outstretched arms, hearing and feeling a crack in her left arm. She did not hit her head or lose consciousness. On EMS arrival, the patient had a left arm deformity distal to left elbow. Her right arm was not deformed. She was put in splints and transferred to the hospital for further evaluation. In the ED...

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