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 to the conscious sedation, including the pre- and postsedation checks, the pulse oximetry (94760-94762) and any monitoring although the monitoring may be done by a nurse or mid-level practitioner. The exception is that physicians also may bill for catheter placement (36000). Although such placement is integral to any intravenous (IV) sedation, non-IV forms are allowable, and the catheter placement would be considered a separate service.

Conscious sedation is billed in addition to the codes for the operative procedure the sedating physician later performs, and in many cases an appropriate E/M code also may be billed.

Justify the Code With Documentation

To code conscious sedation, the coder must verify that the procedure meets the following requirements:

The documentation must say that conscious sedation was done. A reference to giving the patient Demerol and Valium and reducing a thumb fracture (26645, 26650) isnt sufficient.

An independent trained observer, most likely a nurse, must be in the room to monitor the patient.

The patient must be monitored electronically, at least by pulse oximetry.

The physician must perform a procedure. Conscious sedation is not billable if its used merely for pain relief. In addition, the procedure must be performed by the same physician who sedated the patient.

The patient must be monitored after the procedure, until the analgesia wears off.

The patient or a guardian must give informed consent before the sedation is performed.

The physician must complete a presedation physical assessment.

The documentation must also mention the medication used and the route of administration, Herman says. Conscious sedation can be delivered intravenously, through intramuscular injection or inhalation (99141), orally, rectally or intranasally (99142).

Any chart must also meet internal hospital standards for conscious sedation, Roberts says. Its definitely been one of the top issues that the Joint Commission [on Accreditation of Healthcare Organizations] has been looking at. They want to make sure that people are doing it safely. There has to be a hospital policy to ensure what kinds of special precautions are taken.

If the hospital requires use of a blood pressure monitor or cardiac monitor, or the resuscitation equipment is on hand, the documentation must include that information before conscious sedation can be coded.

At Hermans hospital, nurses use a conscious sedation form that includes a presedation history and checklist. But whether such a document is available or not, it falls to coders to ensure that any conscious sedation claim contains all of the documentation necessary to back it up.

Using Alternatives to the Standard Codes

Conscious sedation requires detailed and complex documentation, and often the service simply cant meet the requirements. And no matter how meticulously the service is documented, Medicare still wont pay. If you are unable to bill for the conscious sedation, all elements of the procedure could be considered for an evaluation and management (E/M) level, thus elevating the level based on risk and the complexity of history and physical obtained.

When billing for conscious sedation, coders cannot use any of the pre-, interim, or postsedation documentation to support the E/M code, and they cant bill for incidental procedures, Herman says. But coders who opt not to bill for conscious sedation can use all the information from the preoperative visit and everything else thats documented to justify the complexity of the decision-making and risk factors. Even if the diagnosis is straightforward, a physician may take a comprehensive history because of the potential risks of sedation, and all the other sedation-related details can apply to the E/M code. If I use those same elements to support a higher level of documentation, I cant bill out as many dollars, but I can still bill the 99285 (emergency department visit for the evaluation and management of a patient, which requires these three key components within the constraints imposed by the urgency of the patients clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision-making of high complexity) and Im likely to get paid, says Herman.

In the past, the American Medical Association (AMA) and CPT have said that conscious sedation doesnt satisfy the definition of with anesthesia for codes such as 24605 (treatment of closed elbow dislocation; requiring anesthesia). However, some coders and clinicians have successfully billed such codes when all the conscious sedation criteria are satisfied.

This has been a controversial area even for AMA and CPT staffers. The January 1999 issue of CPT Assistant clearly states that surgery codes with the descriptors with anesthesia refer to general anesthesia. Because conscious sedation is not considered anesthesia, coders may have to choose a surgery code with descriptors without anesthesia and bill the conscious sedation in addition to the surgery code with an understanding that Medicare will not pay for the conscious sedation and the procedure.

Medicare traditionally has given its fiscal intermediaries (FIs) a lot of latitude for interpretation of coding guidelines, and in the absence of recent guidance regarding this issue, coders should check with their FI to learn its policies.