Recently, our surgeon carried out an emergency room consult and administered intravenous sedation to perform an incision and drainage of a perirectal abscess. So if I charge for the consult and the procedure, can I code for the IV sedation also?
Well you can only report an intravenous (IV) sedation
in addition to an E/M and procedure under certain circumstances. Only a conscious sedation is reportable separately and even that is only in some instances.
in addition to an E/M and procedure under certain circumstances. Only a conscious sedation is reportable separately and even that is only in some instances.
If your surgeon carried out conscious sedation, you may be able to bill that with the right documentation and depending on exactly which I&D code you are using. Remember that any code that has the ‘target' symbol in CPT codes includes conscious sedation, which means that you cannot bill the service separately.
If the IV sedation you talked about was conscious sedation for allowable procedure such as 45005 (Incision and drainage of submucosal abscess, rectum), you'll require to document who was monitoring the patient during the case (name and credentials like John Doe, RN). You will also need to document what drug was used and how much as well as the patient's vitals prior to, during, and after the sedation. If you do not have the documentation, you cannot bill for the conscious sedation.
If you cannot bill conscious sedation, you are unlucky for the IV. Beginning an IV is a facility service in the ED; as such you cannot separately bill for starting the IV.
If the IV sedation you talked about was conscious sedation for allowable procedure such as 45005 (Incision and drainage of submucosal abscess, rectum), you'll require to document who was monitoring the patient during the case (name and credentials like John Doe, RN). You will also need to document what drug was used and how much as well as the patient's vitals prior to, during, and after the sedation. If you do not have the documentation, you cannot bill for the conscious sedation.
If you cannot bill conscious sedation, you are unlucky for the IV. Beginning an IV is a facility service in the ED; as such you cannot separately bill for starting the IV.
