ED Coding and Reimbursement Alert

Correctly reporting the performance of conscious sedation in the emergency department (ED) has been a long-standing controversy in emergency medicine. ED physicians must make the distinction between a state of unconsciousness and without any sensation to the area when selecting the appropriate code.

As defined by CPT 2000, conscious sedation is used in tandem with a medical procedure to achieve a medically controlled state of depressed consciousness while maintaining the patients airway, protective reflexes and ability to respond to verbal commands. 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 function.

Commonly, conscious sedation is used when performing delicate and painful or long proceduresfor example, laceration repairon children, the elderly and other adults in certain situations.

In 1998, CPT added two codes for this service: 99141 (sedation with or without analgesia [conscious sedation]; intravenous, intramuscular, or inhalation) and 99142 (sedation with or without analgesia [conscious sedation]; oral, rectal and/or intranasal). Some payersMedicare includedconsider conscious sedation to be bundled into the overall service provided to the patient and do not recognize the conscious sedation codes. To get reimbursed for the additional service related to conscious sedation when the payer does not reimburse for it, some groups have been reporting the overall service with a code that specifies with anesthesia (i.e, 23655, closed treatment of shoulder dislocation, with manipulation; requiring anesthesia).

Note: For more information, see the article Update on Conscious Sedation: When Should You Report an E/M Level or Anesthesia Code? on page 44 of the June 1999 ED Coding Alert.

New Information: Avoid With Anesthesia

Pat Moore, vice president for reimbursement for Healthcare Business Resources, Inc., an emergency medicine billing company in Durham, N.C., however, has received a clarification from the American Medical Association (AMA) indicating that this practice is not appropriate.

I had the opportunity to ask Celeste Kirschner, MHSA, director of CPT Editorial and Information Services at the AMA, about using surgical codes that include the language with anesthesia, she says. According to her, when a CPT code states with anesthesia and the type of anesthesia is not specified, the term anesthesia should be interpreted as general anesthesia.

Moore says she interpreted Kirshners statements to exclude conscious sedation. We are no longer reporting conscious sedation with these codes, Moore explains. According to the new information provided by Kirschner, the CPT editorial panel considers conscious sedation to be analgesia [directed at pain relief] rather than anesthesia [numbing of sensation].

Generally, the CPT Editorial Panel considers general anesthesia to mean a state of unconsciousness and regional anesthesia as without any sensation to the area.

Kirschner acknowledged that CPT does not specifically state that with anesthesia means general anesthesia and emergency physician groups cannot be faulted for interpreting the definition more broadly. But, she indicated that using surgical codes stating with anesthesia for conscious sedationonce a practice is informed of the correct interpretation of that termwould be abusive, Moore advises.

Code Language Meant to Indicate Severity

Conscious sedation is definitely not anesthesia, adds Peter Sawchuk, MD, chair of the American College of Emergency Physicians (ACEP) Coding and Nomenclature Advisory Committee and member of ACEPs CPT Advisory Committee. There has been much discussion about this issue [proper use of the with anesthesia codes]. The language has been subject to wide interpretation.

Originally, the CPT editorial panel used with anesthesia as an indicator of a surgical procedures severity, not necessarily the type of anesthesia given, Sawchuk explains. It was meant to indicate a procedure of the type that is normally performed in an operating room (OR) setting, not in an office or outpatient hospital department, such as the emergency department. Because the actual code definitions are not specific, the term with anesthesia has been interpreted differently by different payers, he acknowledges.

Many emergency medicine coding experts previously have interpreted with anesthesia to mean any kind of anesthesia, including regional and local anesthetics, Moore says.

Kirschner advised that only regional anesthesia would be included in these codes. When I asked about regional anesthesia, she agreed that regional anesthesia would be an appropriate use of the with anesthesia codes, but not in the case of conscious sedation or of digital blocks, Moore says.

Use of Agent in Conscious Sedation

A variety of agents are used in conscious sedationbenzodiazepines, such as diazepam (Valium) and midazolam (Versed); opiates, such as meperidine (Demerol) and fentanyl (Sublimaze); and neuroleptics, like haloperidol (Haldol) and droperidol (Inapsine).

Different drugs offer different benefits and risks in various patient populations, and the emergency physician must be skilled in the uses and contraindications of each drug.

More and more frequently, emergency physicians are using another class of drugsanesthetic induction agentsto perform conscious sedation. Ketamine (Ketalar), propofol (Diprivan) and sodium thiopentone (Pentothal) are just a few of the drugs used for conscious sedation that are in this category. These drugs offer many of the same benefits of the other, analgesic drugs used in conscious sedation, with the added benefit that the patient often has no memory of the procedure.

In many areas, use of these agents is restricted to anesthetists. But in recent years, more emergency physicians are becoming skilled in the use of these drugs.

With anesthetic induction agents, the patient may lose consciousness and not be aware of pain with the procedure, but the drug will not affect respiration and the protective gag reflexes that prevent a patient from choking, says Daryl LaRusso, MD, an emergency physician in Martinsburg, W.Va.

We use ketamine for conscious sedation, particularly with children, he notes. The patient is essentially unconscious, as in general anesthesia. But unlike general anesthesia, you dont have to have ventilatory support because respiration and reflexes are not impaired. Is it only considered anesthesia if you require the respiratory support as well as general?

According to Robert Mills, a spokesperson with the AMA, the editorial panel has never considered ketamine specifically and does not make any distinction for the particular agents used during conscious sedation because conscious sedation is recognized in CPT. According to the personnel I consulted, it would be up to the guidelines for appropriate use of ketamine in that department, Mills advises.

Guidelines published by the American College of Emergency Physicians recognize ketamine as an appropriate agent for conscious sedation. So for payers who recognize the conscious sedation CPT codes, reporting the use of ketamine as conscious sedation is appropriate. I would consider ketamine to fall under conscious sedation, not anesthesia, adds Sawchuk.

The question is whether Medicare, which does not recognize the CPT codes for conscious sedation, will consider the use of ketamine to be an anesthetic or not, even though the AMA considers only general or regional anesthesia to meet that definition.