ED Coding and Reimbursement Alert

But sedation codes still have Medicare -C- status

There is good news for ED coders: Medicare carriers may start paying for more moderate (conscious) sedation codes soon, according to a new transmittal from the Centers for Medicare & Medicaid Services.

Right now, Medicare carriers will only pay for 99148-99150 (Moderate sedation services [other than those services described by codes 00100-01999] provided by a physician other than the healthcare professional performing the diagnostic or therapeutic service that the sedation supports ...), codes that cover a situation in which one physician performs a procedure and another physician sedates the patient.

They won't cover 99143-99145 (Moderate sedation services [other than those services described by codes 00100-01999] provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status ...), codes that cover sedation that a single physician performs in addition to the procedure.

But beginning Oct. 1, -Physicians who both perform, and provide moderate sedation for, medical/surgical services will be paid for the conscious sedation consistent with CPT guidelines,- according to MLM Matters transmittal MM5618.

The new language is a -positive sign- and may show that Medicare is responding to providers- letters in support of moderate sedation, says David McKenzie, CAE, reimbursement director with the American College of Emergency Physicians.

Medicare appears to be saying that the carriers should pay for 99143-99145 when the same physician performs a procedure and sedation, with a trained observer present, says Margaret Loftus, a coder with Stanford Hospital and Clinics in Palo Alto, Calif.

For example: A 25-year-old male presents to the ED complaining of shoulder pain. The physician examines the patient and discovers that he has a dislocated shoulder. The ED physician sedates the patient with Versed and Fentanyl to the point where the patient is very relaxed but still breathing comfortably on his own. The physician then reduces the shoulder. The total bedside time spent overseeing the sedation was 25 minutes.

For this scenario, you would report the following:

• 23650 (Closed treatment of shoulder dislocation, with manipulation; without anesthesia) for the reduction.
• 99144 (... age 5 years or older, first 30 minutes intra-service time) for the sedation.
• 831.00 (Dislocation of shoulder; unspecified) linked to 23650 and 99144 to represent the patient's injury.

Important: Make sure your documentation specifies the level of sedation, and be certain that the ED physician provides moderate sedation before coding it.

-If the physician performing the procedure provides local or minimal sedation for the procedure, then no separate payment is made for the local or minimal sedation service,- the transmittal states.

Confused about what constitutes moderate sedation? Check out this definition: -Moderate sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation,- according to Medicare.

According to the transmittal, Medicare will allow its payers to process these codes for payment in October. But just because carriers can pay for these codes does not mean they will.

The new transmittal gives -no guidance at all as to payment,- Loftus says. -The codes are carrier-priced, which means every Medicare carrier is free to value them as they will.-

According to the transmittal, Medicare assigned the 99143-99145 codes a -C- status indicator under the Medicare physician fee schedule, meaning that -CMS has not established relative value units (RVUs) for these services,- Medicare states.

And as long as these codes are status -C,- the carriers have discretion on whether to pay for them. However, this step means that Medicare may add RVUs to all of the moderate sedation codes in 2008 (or at some other time soon).

Watch out: You can't bill 99143-99150 with the codes listed in Appendix G of the CPT book, because those codes include conscious sedation.

Suppose the ED physician provides moderate sedation for a patient before placing a chest tube. Since CPT lists the chest tube insertion code in Appendix G, you would only report 32020 (Tube thoracostomy with or without water seal [e.g., for abscess, hemothorax, empyema] [separate procedure]) on the claim and not report the moderate sedation service.