Anesthesia Coding Alert

Some injections can be very painful, requiring that the patient receive a sedative. For example, a steroid may be injected into an old injury that has healed imperfectly and is causing significant discomfort. Steroid injections may also be administered to patients with lupus erythematosus or carpal tunnel syndrome conditions that cannot be helped surgically. In addition, some patients suffer from specific conditions that render them unable to be still or to relax for treatment, such as spasticity, paraplegia or extreme anxiety, says Martina Heasley, director of practice planning for the Stanford University department of anesthesia in Stanford, Calif. In these situations, pain physicians may administer conscious sedation (CS).

During CS, the patient is in a medically controlled depressed consciousness, and the presence of a nurse is required to monitor vital signs. The patients airway and protective reflexes are maintained, and the patient is still able to respond to stimulation or verbal commands.

Coding the Service

In 1998, CPT introduced codes 99141 (sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation) and 99142 (... oral, rectal and/or intranasal) to allow reporting of conscious sedation services by practitioners other than anesthesiologists or nurse anesthetists. Although Medicare does not pay for these codes, some private and noncommercial carriers do reimburse the service.

According to the CPT introduction, conscious sedation includes performance and documentation of pre- and post-sedation evaluations of the patient, administration of the sedation and/or analgesic agent(s), and monitoring of cardiorespiratory functions (i.e., pulse oximetry, cardiorespiratory monitor and blood pressure). These codes require the presence of an independent trained observer to assist the physician in monitoring the patients vital signs, level of consciousness and physiological status during the procedure.

Note: If an anesthesiologist or a nurse anesthetist administers conscious sedation, anesthesia codes are used to report the service.

CS might be used for bedside treatment of an inpatient. Codes 99141 and 99142 should not be billed for procedures performed in the hospital, however, because the physician does not own the equipment or the medicine, and likely will instruct a nurse (who is employed by the hospital) to monitor the patient. Moreover, CS is insufficient for any procedures that require a trip to the operating room, Heasley says.

Carrier Guidelines Vary

When performed in the office where the nurse is an employee of the physician payment policies for these procedures vary greatly. Shortly after CPT introduced 99141 and 99142, Medicare began to instruct providers not to bill for CS because it is considered part of the surgerys global package.

Some private carriers, however, in particular managed care companies, will cover 99141-99142, as do several non-Medicare public-sector plans. For example, the Minnesota Health Care Program now instructs physicians to bill for 99141 (and when doing so, to include in the claim the name and amount of the drug used, and what it was used for).

Wellmark Blue Cross Blue Shield of South Dakota also pays for CS, instructing the operating physician to bill 99141 or 99142 on the same claim form as the charge for the surgery with the same date of service. Only one unit should be billed on the HCFA 1500 form, Wellmark says.

Wellmarks instructions also note, although these procedures require the presence of an independent trained observer (e.g., a nurse or physicians assistant), they give the physician the ability to perform minor surgery, usually in the office, and sedation without the services of an anesthesiologist or a certified registered nurse anesthetist.

Wellmark recognizes a bargain when it sees one, Heasley comments.

Meanwhile, North Carolina workers compensation now covers 99141 and 99142 in its Medical Fee Schedule by report. Such a report should indicate that the procedure was performed in the pain physicians office, and that the nurse monitoring the machines is employed by the practice, says Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C.

Documentation must indicate that the physician personally did all the preliminary work on the patient and that the sedation was administered by the physician or a nurse employed by the practice. The physician should also provide a postoperative report that includes any adverse reaction to the sedation.

Because CS policies are carrier-specific, practices should contact their payer to determine its stand on this issue.