Head Wound Procedure and Sedation Coding

Posted By AHIMA Staff on Mar 26, 2012

A 5-year-old patient was brought into the emergency room with a deep 2-cm laceration of his scalp. The child was combative and would not allow staff to cleanse the wound. The mother held the child in her lap while the ED physician administered 10 mg of Versed intranasally.

When the child was sufficiently sedated, one of the ED nurses monitored the patient’s vital signs, and the physician performed a layered repair of the laceration. The intra- service time for the procedure did not exceed 30 minutes.  Assign the correct CPT code(s) for the procedure and sedation for this case:
[QUIZZIN 75]