ED Coding and Reimbursement Alert

Watch for shorter time thresholds.

There will be 727 changes to the CPT^® code set in 2017, with 148 additions, 81 deletions and 498 revisions to CPT^® coding in 2017. Now’s the time to bone up on the changes most relevant to emergency medicine.

There were no significant changes in the E/M code section, says Michael Granovsky, MD, FACEP, CPC, President of LogixHealth, a national ED coding and billing company based in Bedford, MA. And the vaccine codes in the medicine section see just the usual updates, including tweaks to the composition or dosage information, he says. For example influenza codes will now be coded by dosage rather than age.

Wake Up to New Moderate Sedation Codes in 2017

The prior moderate (conscious) sedation codes (99143-99150) have been deleted and replaced with new codes in 2017. Now providers who perform moderate sedation with a procedure must report the appropriate new moderate sedation code (99151-99157) to receive full payment.

The new codes look similar to the prior codes. You’ll see three codes describing moderate sedation for both situations where the sedation is provided in support of your own procedure, as well as when it’s for another provider’s procedure. The three codes for each of these scenarios include one code for patients under age five, one for age five and over, and an add-on code for additional time providing moderate sedation. The new codes are:

• 99151 (Moderate sedation services provided by the same physician or other qualified health care professional 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; initial15 minutes intra-service time, patient younger than 5 years of age)
• 99152 (…initial 15 minutes intra-service time, patient age 5 years or older)
+• 99153 (each additional 15 minutes of intra-service time [List separately in addition to code for the primary service)
• 99155 (Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intra-service time, younger than 5 years of age)
• 99156 (…initial 15 minutes intra-service time, patient age 5 years or older)
+• 99157 (…each additional 15 minutes of intra-service time [List separately in addition to code for the primary service)

The biggest change is that the intraservice time thresholds have dropped from 30 minutes to 15 minutes. CPT^® instructs that for any time-based code, a unit of time is attained when the midpoint is passed, unless there are code- or code range- specific instructions in the guidelines, parenthetical instructions, or code descriptors to the contrary.

CPT^® 2017 includes a chart, similar to the one in the critical care code section, which lists the correct moderate sedation code to assign based on the provider situation and the total intraservice time. This chart does provide code range-specific instruction not to report a moderate sedation code if the intraservice time is less than 10 minutes. That specific instruction would override the midpoint time of eight minutes that would otherwise be the standard. This is an important point that physician’s and coders need to understand, says Granovsky.

Just What is Included in Intraservice Time?

Also new in the 2017 moderate sedation preamble, are extensive descriptions of what is included in the pre-, intra- , and post-service work periods. This is important to understand because only the intraservice time can be reported in the required time threshold for each code descriptor.

The following pre-service work components are not included when determining intra-service time:

• A thorough screening history involving assessment of the patient’s past medical and surgical history with particular emphasis on cardiovascular, pulmonary, airway, or neurological conditions, review of the patient’s previous experience with anesthesia or sedation and any family history of sedation complications, summary of the patient’s present medication list and any drug allergy and intolerance history.
• A physical exam including focused emphasis on the mouth, jaw, oropharynx and airway for Mallampati score assessment, chest, lungs, heart and circulation, vital signs including oxygenation with end tidal C02 when indicated.
• A review of any pre-sedation diagnostic tests, completion of a sedation assessment form and obtaining informed consent.
• Starting IV access and fluids to maintain patency.

Similarly the following post-service work components are not included when determining intraservice times reported:

• Assessment of the patient’s vital signs, level of consciousness, neurological, cardiovascular and pulmonary stability in the post-sedation recovery period.
• Assessment of the patient’s readiness for discharge.
• Documenting the sedation service.
• Communicating to family members or caregivers regarding the sedation service.

That leaves these activities as recognized intraservice work components and included in the moderate sedation time reported:

Intra-service time begins with the administration of the sedating agent. It requires continuous face-to-face attention of the provider, and monitoring of the patient’s response to the sedation, periodic reassessments, and vital signs including oxygenation, heart rate, and blood pressure.

The moderate sedation intraservice time ends when the procedure is completed, the patient is stable, and the provider providing sedation ends personal face-to-face care of the patient says Granovsky.