ED Coding and Reimbursement Alert

Limited acceptance and tough documentation standards make coding for conscious sedation difficult. But there are ethical ways to optimize reimbursement for this procedure.

On the surface, conscious sedation sounds like a simple issue. The physician sedates a patient, often a child, using medications to alter behavior and mood. Under mild or moderate sedation, the patients respiratory drive and protective reflexes are still active, but presumably the doctor can perform a painful or stressful procedure with minimal discomfort to the patient.

The procedure works especially well with children or anyone who requires a fracture reduction or treatment of a burn or complex laceration, says Martin Herman, MD, FACEP, president of Pediatric Emergency Specialists, a fee-for-service contract physician group in Memphis, Tenn.

So whats the problem? Documentation and justification of the conscious sedation codes (99141, 99142) can be somewhat complex, and many government payers dont reimburse for it. Herman believes thats a mistake. Doctors in the emergency department (ED) are sedating thousands of children a day, and providing a fairly high level of service that we believe is saving money for payers because its preventing operating room (OR) time.

Mistake or not, coders still must know how to deal with conscious sedation. To make the most of the physicians services, coders should understand:

Who will pay for conscious sedation and who wont.
What documentation is required to justify the code.
How to use alternatives to the standard codes.

Who Will and Wont Pay for Conscious Sedation

Now Medicare wont pay for conscious sedation, says Sam Roberts, MD, FACEP, president of Third Coast Emergency Physicians, an ED staffing network in Austin, Texas. Theres a move right now to get Medicare to pay for this because it is sometimes the only way to get something done without going through general anesthesia, which is a lot more risky and expensive.

Because Medicare could change its policy at any time about conscious sedation or other coding issues coders should check the Health Care Financing Administration (HCFA) Web site at www.hcfa.gov frequently to see whats happening.

State Medicaids also tend to deny the conscious sedation codes. However, many commercial payers will reimburse for the procedure, some at a better rate than others. Coders and billers should learn which major payers in their area accept conscious sedation and use the codes whenever feasible.

For payers that honor the codes, conscious sedation can be used with any procedure for which such treatment is appropriate. Fractures and lacerations are the most common, but CPT rules dont limit physicians regarding when they can perform conscious sedation.

Codes 99141 (sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation) and 99142 (oral, rectal and/or intranasal) encompass all the services related [...]