ED Coding and Reimbursement Alert

New codes for sedation and late-night care lighten your reporting burden

If you-ve been confused about when--and when not--to report conscious sedation or after-hours codes, CPT's code changes for 2006 will ease your struggles. Six new moderate sedation codes and clearer guidelines for 24-hour facilities will take the sting out of reporting these services.

CPT has changed -conscious sedation- to -moderate sedation- in the 2006 edition. Based on 2005 CPT changes, if you see a procedure code with a target symbol (  . ), you will not often be able to report moderate sedation separately with that procedure, says Michael A. Granovsky, MD, CPC, FACEP, vice president of Medical Reimbursement Systems, an ED billing company in Stoneham, Mass.

Instructions in Appendix G of CPT explain that certain codes include moderate (conscious) sedation as an inherent part of providing the procedure. The CPT book identifies these codes with the target symbol. The instructions note that if the same physician provides a -targeted- procedure and the moderate sedation, -it is not appropriate - to report both the service and the sedation codes 99143-99145.-

Just the facts: You can't bill separately for 99143, 99144 or 99145 (see -Meet Your New Time-Sensitive MS Codes- on the next page for complete definitions of the new sedation codes) if the ED physician provides both a targeted service and moderate sedation.
 
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If the same physician is both providing the moderate sedation and performing the procedure, you are required to have an independent, trained observer on hand to help monitor the patient.

Documentation should provide proof of the observer's presence and document the monitoring of the patient's cardiorespiratory functions (pulse oximetry, cardiorespiratory monitor, and blood pressure) for the duration of the moderate sedation. In addition, the physician documentation will often reflect a presedation and postsedation assessment, Granovsky says.

Frequently, this documentation is recorded -using an institutional sedation flow sheet that is filled out by the nurse for the bedside vital signs and co-signed by the doctor,- Granovsky says.

Check the Details for 99148-99150
 
You may be able to report 99148-99150 for moderate sedation the physician provided in support of an Appendix G -targeted- procedure, but the service must meet two requirements:

1. As required by the code descriptors, a second physician (not the physician providing the service that supports the moderate sedation) must provide the MS.

2. The targeted procedure supporting the moderate sedation and the sedation itself must take place in a -facility setting- (such as a hospital or outpatient hospital/ ambulatory surgery center)--which includes the ED.
  
Watch the Time for 99053

In a move that will clarify ambiguity about reporting after-hours codes in the ED, CPT has eliminated 99052 and 99054 in favor of new code 99053 (Service[s] provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service), says Joan Gilhooly, CPC, CHCC, president of Medical Business Resources in Deer Park, Ill. Medicare won't pay separately for the new code--the payer has bundled that payment into the relative value units for your other services--but some private payers will, she says.

Many groups opt not to report the after-hours codes because patients complain about the additional charges, but others bill because they believe the extra expense and effort involved in late-night staffing needs proportional compensation, she says.

The vast majority of private payers haven't been reimbursing for these special services codes. But if the private payer doesn't compensate you, there may be an opportunity to bill the patient, depending on your contracting status and state laws.