Anesthesia Coding Alert

Question: Can we code for conscious sedation during pain management procedures? If so, should we submit additional documentation?

New Jersey Subscriber
 
Answer: You can report 99141 (Sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation) in conjunction with some pain management procedures. Medicare doesn't reimburse for conscious sedation codes, but some private carriers will.
 
Pay attention to CPT's guidelines for reporting conscious sedation, noted just above the codes. Among other things, the case must require "the presence of an independent trained observer to assist the physician in monitoring the patient's level of consciousness and physiological status." This "independent trained observer"  is almost always a registered nurse, who administers the conscious sedation according to the physician's orders. If an anesthesiologist or CRNA provides this service, bill it as monitored anesthesia care. Documentation should include notes on the injection or IV placement, medications administered, start and stop times, and the person monitoring the patient.