# 99144 in an ASC



## sarthur (Jan 18, 2016)

My pain management doctor frequently performs procedures at an ASC and provides sedation (99144). However, I read a Q&A article in the September issue of Medicare Part B news (http://pbn.decisionhealth.com/Articles/Detail.aspx?id=520562) that stated pain management doctors should not bill for moderate conscious sedation (99144) in an outpatient setting when the conscious sedation is being administered by a nurse who is an employee of the facility, not an employee of the physician. So, can anyone help me with other documentation supporting or disproving that the nurse administering the drug needs to be an employee of the physician? My doctor said he could administer meds before gloving for the procedure but he finds it hard to believe this is how all the other pain mgmt drs are doing things as well. Any help would be greatly appreciated!


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## dwaldman (Jan 19, 2016)

Since I was not able to open link that you provided, I was able to see what was referenced on why the article stated the physician can not report conscious sedation in ASC when the RN ( an employee of the ASC) performs as the trained observer. Below I looked at the Medicare claims processing manual, for ASCs it states that "monitoring of anesthesia" is included in the facility fee. For the anesthesia section in the physician portion of the Medicare claims processing manual, there is description of moderate sedation but it does relay their stance of if it is performed in the ASC with an employee of the ASC. Maybe someone that has more experienced with this could have first hand knowledge of it or familiar with the reasoning in the article you provided.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c14.pdf

Medicare Claims Processing Manual Chapter 14 - Ambulatory Surgical Centers  Table of Contents (Rev. 3430, 12-29-15)  

ASC services for which payment is included in the ASC payment for a covered surgical procedure under 42CFR416.65 include, but are not limited to-  

(13) Materials, including supplies and equipment for the administration and monitoring of anesthesia; and 


https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician Practitioners  Table of Contents (Rev. 3315, 08-06-15) (Rev. 3368, 10-09-15) (Rev. 3402, 11-06-15)  

Anesthesia and Medical/Surgical Service Provided by the Same Physician  

Anesthesia services range in complexity.  The continuum of anesthesia services, from least intense to most intense in complexity is as follows:  local or topical anesthesia, moderate (conscious) sedation, regional anesthesia and general anesthesia.  Prior to 2006, Medicare did not recognize separate payment if the same physician provided the medical or surgical procedure and the anesthesia needed for the procedure.  
Moderate sedation is a drug induced depression of consciousness during which the patient responds purposefully to verbal commands, either alone or accompanied by light tactile stimulation.  Moderate sedation does not include minimal sedation, deep sedation or monitored anesthesia care. In 2006, the CPT added new codes 99143 to 99150 for moderate or conscious sedation.  The moderate (conscious) sedation codes are carrier priced under the Medicare physician fee schedule.  
The CPT codes 99143 to 99145 describe moderate sedation provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status.  The physician can bill the conscious sedation codes 99143 to 99145 as long as the procedure with it is billed is not listed in Appendix G of CPT.  CPT codes 99148 to 99150 describe moderate sedation provided by a physician other than the health care professional performing the diagnostic or therapeutic service that the sedation supports.  
The CPT includes Appendix G, Summary of CPT Codes That Include Moderate (Conscious) Sedation.  This appendix lists those procedures for which moderate (conscious) sedation is an inherent part of the procedure itself.  CPT coding guidelines instruct practices not to report CPT codes 99143 to 99145 in conjunction with codes listed in Appendix G.  The National Correct Coding Initiative has established edits that bundle CPT codes 99143 and 99144 into the procedures listed in Appendix G.  
In the unusual event when a second physician other than the health care professional performing the diagnostic or therapeutic services provides moderate sedation in the facility setting for the procedures listed in Appendix G, the second physician can bill 99148 to 99150.  The term, facility, includes those places of service listed in Chapter 23 
Addendum -- field 29.  However, when these services are performed by the second physician in the nonfacility setting, CPT codes 99148 to 99150 are not to be reported.  
If the anesthesiologist or CRNA provides anesthesia for diagnostic or therapeutic nerve blocks or injections and a different provider performs the block or injection, then the anesthesiologist or CRNA may report the anesthesia service using CPT code 01991.  The service must meet the criteria for monitored anesthesia care.  If the anesthesiologist or CRNA provides both the anesthesia service and the block or injection, then the anesthesiologist or CRNA may report the anesthesia service using the conscious sedation code and the injection or block.  However, the anesthesia service must meet the requirements for conscious sedation and if a lower level complexity anesthesia service is provided, then the conscious sedation code should not be reported.  
If the physician performing the medical or surgical procedure also provides a level of anesthesia lower in intensity than moderate or conscious sedation, such as a local or topical anesthesia, then the conscious sedation code should not be reported and no payment should be allowed by the carrier.  There is no CPT code for the performance of local anesthesia and as payment for this service is considered in the payment for the underlying medical or surgical service.


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## sarthur (Jan 21, 2016)

*ASC employee - 99144??*

Thank you for the help, dwaldman. I may be misreading your post, but I do not see where in the information you pulled from the Medicare processing handbook Medicare "relay their stance of if it is performed in the ASC with an employee of the ASC." ??

I guess the second question I have would be about the language of the code description "requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status." The code requires an second person to monitor the patient under moderate sedation. Is my doctor supposed to hire someone to take with him to the ASC if he can't use an ASC employee as the trained observer for his 99144 services??


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## agibb1022 (Jan 21, 2016)

sarthur said:


> My pain management doctor frequently performs procedures at an ASC and provides sedation (99144). However, I read a Q&A article in the September issue of Medicare Part B news (http://pbn.decisionhealth.com/Articles/Detail.aspx?id=520562) that stated pain management doctors should not bill for moderate conscious sedation (99144) in an outpatient setting when the conscious sedation is being administered by a nurse who is an employee of the facility, not an employee of the physician. So, can anyone help me with other documentation supporting or disproving that the nurse administering the drug needs to be an employee of the physician? My doctor said he could administer meds before gloving for the procedure but he finds it hard to believe this is how all the other pain mgmt drs are doing things as well. Any help would be greatly appreciated!



I'm not sure if this will be helpful or not since I don't work with a pain management dr, but I do work for an ASC so I might be able to give some info.  ASC procedures are different in that all the services are not separately reimbursable.  All of your conscious sedation, supplies, IV fluids, etc are included in the reimbursement for the procedure.  Not like in other settings where they can charge for everything separately...like a tylenol or a bag of IV fluids.  So, all of our RNs and our Gastroenterologist are trained to administer and monitor the conscious sedation.  The only time sedation can be billed separately is if it is propofol (or something similar) that requires an anesthesiologist.  And then it's just the anesthesiologist billing it for themselves, we do not receive any additional reimbursement.  We can not bill the 99144 since it considered included in the procedure code.  There is a list of all procedures that include conscious sedation in the CMS Manual.  
Hope that helps.


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## sarthur (Jan 22, 2016)

amandagibb1022@gmail.com, thank you for your response! I am doing the professional billing for the physician performing services in the ASC not the billing for the facility, so 99144 is reimbursable. I am just thrown by the article (that this thread won't let me attach, sorry!!) stating the physician cannot bill for the ASC nurse providing the required independent observation while the patient is under sedation since she is an employee of the ASC. I cannot find any other source to support this position to explain it further to my physician. I'm wondering if it is even an accurate article at this point....


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## agibb1022 (Jan 22, 2016)

sarthur said:


> amandagibb1022@gmail.com, thank you for your response! I am doing the professional billing for the physician performing services in the ASC not the billing for the facility, so 99144 is reimbursable. I am just thrown by the article (that this thread won't let me attach, sorry!!) stating the physician cannot bill for the ASC nurse providing the required independent observation while the patient is under sedation since she is an employee of the ASC. I cannot find any other source to support this position to explain it further to my physician. I'm wondering if it is even an accurate article at this point....



Good afternoon! I think that my situation is completely different from yours and that my opinion is not helpful at all.  I also do the professional billing for the same procedures that I do the ASC billing for.  The gastroenterologist owns the physician practice and the ASC and does all the procedures.  We don't bill for the 99144 on the professional side either.  I've worked for him for 2 years, but he's been 'in the business' for 30+ years.  I really hope he/I haven't been doing it wrong this whole time.  Please keep me updated.  I am very curious about this!  
  Sorry.


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## Melissa Harris CPC (Jan 3, 2017)

Hello,

Has anyone gotten a definitive answer on this?  My physicians performs pain management procedures at the ASC and we have been billing for Moderate Sedation that is administered/monitored by an employee of the ASC.  I know that the moderate sedation is included in the ASC services, but can I bill it for the physician?

Any help is greatly appreciated

Melissa Harris, CPC


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## dwaldman (Jan 7, 2017)

Melissa, the below link has a large section of moderate sedation, I also reviewed a UHC policy which didn't require the observer being an employee or the fact it was in an ASC. In the link below they only state the trained observer has to place their credential on the moderate sedation form. They don't state the observer has to be an employee of the physician.


http://www.palmettogba.com/Palmetto/Providers.Nsf/files/Anesthesia_Billing_Guide.pdf/$File/Anesthesia_Billing_Guide.pdf


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