tci ED Coding & Reimbursement Alert - 2009 Issue 11

You Be the Coder: Coding ED Sedation Services

Question: A 2-year-old patient reports to the ED. The father says the baby has not defecated in four days, and has been crying almost nonstop for the past 12 hours. The physician takes a detailed history and during a detailed exam, the physician diagnoses fecal impaction. The physician performs sedation with Versed and performs disimpaction; she then counsels the father on caring for the child and recommends a follow-up visit with the child's primary care physician within two weeks. I reported 45915 for the dismpaction and got a denial. What happened? Ohio Subscriber Answer: You should have coded the...

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