ED Coding and Reimbursement Alert

When performing delicate and painful procedures on children, the elderly, and some other adults in special situations, ED clinicians often employ a service known as ?conscious sedation? to facilitate the performance of the procedure with a minimum of discomfort to the patient and the physician.

For example, a parent brings in a young child with a facial laceration requiring several stitches. Certainly, an analgesic will be given so that the child won?t feel the pain of the sutures; but in many cases, the physician will also want the child to be sedated so that he or she won?t move during the delicate procedure.

?You would want to do this with other patients as well. Elderly patients who present with dislocated shoulders, for example, or people who are mentally challenged who just aren?t going to understand you coming at them with needles,? adds John Stimler, DO, FACEP, a practicing emergency physician in Jacksonville, FL, and a past president of the Florida chapter of the American College of Emergency Physicians.

Correct coding for the administration of conscious sedation is challenging for many ED coders primarily because reimbursement varies from payer to payer. In addition, this procedure requires several different clinical services, medications, and significant documentation that the coder must recognize in order to bill these services as ?conscious sedation.?

What Is Conscious Sedation?

Separate from medication to prevent pain, conscious sedation is the administration of drugs that will put the patient in a lower state of consciousness, but will not put them ?all the way under? as with the use of general anesthesia during surgery.

CPT defines conscious sedation as ?sedation with or without analgesia to achieve a medically controlled state of depressed consciousness while maintaining the patient?s airway, protective reflexes, and ability to respond to stimulation or to verbal commands.?

Drugs used to induce conscious sedation vary depending on the patient and the procedure being performed, says Stimler. Intravenous administration of medications (99141-sedation with or without analgesia [conscious sedation]; intravenous, intramuscular, or inhalation) is used more for dislocations and fracture reductions, he adds. The medications most commonly used would be Versed, morphine, meperidine hydrochloride (Demerol), or fentanyl.

?Ketamine is more commonly used in the pediatric age group and is usually given by injection,? he adds.

Oral medications are usually given to older patients or children who need to be very still for a CAT scan or MRI; chloral hydrate is the most common agent in these instances, says Stimler. Code 99142 is used for ?oral, rectal and/or intranasal? drug administration.

Performance of conscious sedation requires that these drugs be administered in the presence of a trained observer besides the ED physician (who is often the ED nurse), and that the patient?s blood pressure, cardiac rhythm and respiration be monitored.

Medicare Doesn?t Pay

The most significant obstacle to getting paid for conscious sedation is the fact that Medicare does not reimburse for these codes, says Stimler.

?Medicare does not pay for this and some state Medicaids have followed their lead,? he adds.

However, Medicare has assigned the conscious sedation codes relative value units (RVUs) in its fee schedule, notes Pat Moore, vice president of reimbursement services for Healthcare Business Resources, Inc., a large emergency medicine billing company based in Durham, NC. ?They assigned a value to these codes, which would indicate that they didn?t intend to prevent other payers from reimbursing for these services even though they do not.?

In fact, Moore says her experience has been that many commercial third-party payers and several state Medicaid carriers do pay for conscious sedation. ?We haven?t had any significant denials from commercial insurance payers and Medicaids in certain states are paying for it.?

The challenge for coders is to determine which payers do pay for conscious sedation and which don?t. They will then have to adjust their coding depending on specific payer requirements.

For Medicare and the payers who don?t pay for conscious sedation, Moore suggests billing an E/M visit level (99281-99285 for emergency services) in addition to the procedure (i.e., laceration repair, fracture reduction, etc.).
?I would bill a visit level because of all the monitoring of the patient that you have to do,? she says. ?You are giving a parenteral drug in most cases. And, it is often a drug that is a scheduled substance. I would bill an appropriate visit level for the amount of evaluation and monitoring that you are doing.?

Conscious sedation does require constant monitoring and decision-making by the physician in attendance.

?What will happen after the medication is given is the patient gradually lapses into a lower level of consciousness,? says Stimler, describing how the procedure works. ?Then you start manipulating the [body] part being examined to see how sedated they are. It?s a balance between giving them enough [medication] to knock them out so that they won?t have any memory of the procedure, but not so far down that they are not breathing and require respiratory support. You also have to have on hand the drug that will reverse the process. Some people take it into the room with them, as well.?

Documentation is Essential

Obviously, precise documentation of the E/M services performed is required if you want to bill a visit level instead of conscious sedation codes.
But, CPT is also very specific about the clinical requirements that accompany the performance of conscious sedation, says Stimler.

The CPT verbiage reads: ?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 (i.e., pulse oximetry, cardiorespiratory monitor, and blood pressure). The use of these codes requires the presence of an independent trained observer to assist the physician in monitoring the patient?s level of consciousness and psychological status.?

Because CPT is so specific about requiring monitoring of blood pressure, cardiorespiratory function, etc., it is important that documentation be kept that the patient was, in fact, adequately monitored.

One solution to ensuring adequate documentation in the event of an audit, Stimler believes, is to include the nursing notes with the patient?s chart. The ?independent trained observer? present will most likely be an RN, and the nursing notes will document this.

?Physicians should always save their documentation for later use in the event of an audit and I think it would be nice to have the nursing notes in there as well,? he explains. ?The nurse will most likely have written the time [that the patient was sedated], the specific procedure performed, and the name of the physician performing the procedure. And, they will also document the pulse oximetry?what percent of oxygen saturation was maintained, etc. They may even put the cardiac rhythm in there. Or, if not, they will almost certainly mention that the patient was hooked up to a cardiac monitor.? Nursing notes typically include the patient?s blood pressure and pre- and post-sedation evaluations, too.

Note: The ED physician should be encouraged to keep careful documentation of these procedures. Not all payers will accept nursing documentation and, in many cases, the coder will not have access to this information.

Procedure Codes that Include Anesthesia

It is important to note that some procedure codes include the phrase ?with anesthesia? in CPT, notes Moore.

In this situation, the conscious sedation codes cannot be used in addition to the code for the procedure. However, this can work to the coders? advantage if that particular payer does not recognize 99141-99142.

?For instance, if you?ve reduced a dislocation of the hip, there are codes for use with anesthesia and without (27250-closed treatment of hip dislocation, traumatic, without anesthesia; 27252-requiring anesthesia),? Moore
continues. ?So, if your conscious sedation wasn?t going to be covered separately, you could just use the procedure of ?reduction of the hip with anesthesia? and the reimbursement would be higher. It depends; you have to check the RVUs. I would prefer to bill the conscious sedation rather than the procedure code that included anesthesia.?

Billing an E/M Visit Level

Moore believes it is appropriate to bill an E/M level in addition to the procedure code if the payer is not going to recognize the conscious sedation service.

Although Medicare considers the administration of conscious sedation bundled into the procedure, the evaluation and monitoring of the patient constitute a separate service, she states.

?As long as your documentation justifies a separate E/M service, then you can bill a visit level and, certainly, if you have performed conscious sedation, you have performed a separate service and should bill for it.?

Note: The emergency service E/M code (99281-99285) would have to be accompanied by a -25 modifier for most payers. Although it has traditionally been thought that a code with the -25 modifier attached must have a separate ICD-9 code from the other procedure or service performed, CPT and HCFA have recently clarified that this is not the case. Under the definition of the -25 modifier in CPT 1999, it states ?the E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date.?