Anesthesia Coding Alert

UnitedHealthcare to reimburse moderate sedation for most cases

UnitedHealthcare (UHC) will begin reimbursing practitioners for most cases of moderate sedation beginning later this year, according to its April 2007 Network Bulletin.

Old policy: The carrier's current policy states that you cannot report ...quot; or be reimbursed for--moderate sedation services as a separate procedure. The physician's global payment for diagnostic and therapeutic services includes reimbursement for moderate sedation.

New policy: Effective in the third quarter of 2007, UnitedHealthcare will change its policy so that it will separately reimburse for moderate sedation when your physician administers it with a procedure not listed in CPT's appendix G (Summary of CPT codes that include moderate [conscious] sedation). The moderate sedation codes you'll be able to report include:

• 99143--Moderate sedation services (other than those services described by codes 00100-01999) 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; younger than 5 years of age, first 30 minutes intra-service time

• 99144--... age 5 years or older, first 30 minutes intra-service time

• +99145--each additional 15 minutes intra-service time (list separately in addition to code for primary service).

Exceptions: This policy change does not apply to several radiation/oncology procedures. You still cannot report moderate sedation with procedures such as:

• 77280-77295--Therapeutic radiology simulation-aided field setting

• 77300--Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and depth dose, as required during course of treatment, only when prescribed by the treating physician

• 77326-77328--Brachytherapy isodose plan

• 77336--Continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment documentation in support of the radiation oncologist, reported per week of therapy

• 77370--Special medical radiation physics consultation

• 77781-77784--Remote afterloading high-intensity brachytherapy. 

Change Affects Some Groups, Not Others

The policy change shouldn't be too difficult for you to learn because it follows CMS' guidelines on the subject. But it is also a change that might--or might not--affect your coding, depending on your practice.

Why that is: Some anesthesia groups rely on MAC (monitored anesthesia care) during procedures instead of moderate (or conscious) sedation, which means they still won't report the moderate sedation codes. Other groups, however, sometimes use moderate sedation for pain management injections or other procedures, so they are glad to see the change.

"We use conscious sedation for almost 75 percent of our patients, mainly for facet joint, transforaminal or SI (sacroiliac) joint injections and for SCS (spinal cord stimulation)/pump trials," says Eman Danial of Great Lakes Pain Management in Willoughby Hills, Ohio. "The change is not going to affect our coding much because we already bill for it. However, it will affect our reimbursement when we start getting paid."

Example: Danial says the average reimbursement for 99144 is $80 and reimbursement for 99145 is $19. "I checked UnitedHealthcare's fee schedule, and it will approve $79.13 for 99144 and $19.67 for 99145 per 15 minutes," she says. "Our UHC patient volume is around 5 to 6 percent of our patient mix. We are a very busy practice, so this number is going to be significant."

Next steps: Some other carriers such as Palmetto GBA, Anthem and some workers' compensation plans already reimburse physicians for moderate sedation. If your physician provides the service, keep checking carrier policies to learn of others that will reimburse for the service when appropriate.