Ask a Rev Cycle Expert: Fecal Impaction Removal?
Question:
A patient arrived in the emergency department (ED) with fecal impaction. The impaction was not relieved with medication or enema. Intravenous (IV) sedation with midazolam and fentanyl. Can we report code 45915 Removal of fecal impaction or foreign body (separate procedure) under anesthesia?
Answer:
For your scenario, the fecal impaction would be reported with the appropriate evaluation and management (E/M) code. The Current Procedural Terminology (CPT®) code descriptors that include “requiring anesthesia” or “under anesthesia” require the use of general anesthesia.
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