ED Coding and Reimbursement Alert

Question: I have a question regarding the use of the 99148-99150 code. In our practice we see a lot of pediatric patients with fractures and perform conscious sedation to allow the Orthopedist to do the fracture reduction and cast the patient.

Our coders are stating that they cannot give us credit for the sedation under the 99148-99150 “Moderate Sedation provided by a physician, other than the health care professional performing the diagnostic or therapeutic service that the sedation supports,...” because our Emergency Department is “classified” as an outpatient setting as determined by the types of codes we use. They are also telling me that use of this CPT^® code only applies to procedure codes listed in Appendix G.

Is this accurate or should we be receiving the RVUs under 99148-99150 for the sedation that we perform? Thanks for the help.

Hawaii Subscriber

Answer: This is a complex area of frequent uncertainty and would benefit from some further clarity.

ED physicians routinely perform moderate conscious sedation (MCS) in the scenario you describe and bill the MCS codes. In fact, Emergency Physicians are one of the most frequent providers of MCS services. There is nothing in CPT^® that prohibits the MCS codes from being reported in the outpatient setting.

Appendix G can also be very confusing so this is an excellent issue for discussion. Typically if you are performing a procedure listed in Appendix G you cannot also report MCS, as the MCS is felt to be an inherent (bundled) component of the valuation of the procedure. If you are performing any other procedure MCS is reportable. If you are performing sedation in support of another physician performing an Appendix G procedure you can still report MCS if you are in a facility based setting such as the emergency department.

The uncertainty may be due to the following introductory language from the MCS section of CPT^®:

“When a second physician or other qualified health care professional other than the health care professional performing the diagnostic or therapeutic services provides moderate sedation in the facility setting (e.g., hospital, outpatient hospital/ambulatory surgery center, skilled nursing facility) for the procedures listed in Appendix G, the second physician or other qualified health care professional reports 99148-99150. However, for the circumstance in which these services are performed by the second physician or other qualified health care professional in the non-facility setting (e.g., office, freestanding imaging center), codes 99148-99150 are not reported.”

Compare that with the language from the introduction to Appendix G:

In the unusual event when a second physician or other qualified health care professional other than the healthcare professional performing the diagnostic or therapeutic services provides moderate sedation in the facility setting (e.g., hospital, outpatient hospital/ambulatory surgery center, skilled nursing facility) for the procedures listed in Appendix G, the second individual can report 99148-99150. However, for the circumstance in which these services are performed by the second individual in the non-facility setting (e.g., office, freestanding imaging center), codes 99148-99150 would not be reported.

Review this: This summary information that may shed further light on the complex topic of MCS in the ED that may help understand the MCS coding and documentation.  

For coding, there are two groups of codes that can be reported.

• 99143-99145 are reported when the MCS is provided by the same physician performing the procedure that requires the sedation.

• 99148-99150 are reported when the MCS is provided in support of another physician performing the procedure that requires the sedation.

These two groups of codes are further refined by the patient’s age, younger than 5 years of age versus age 5 years or older, first 30 minutes intra-service time.

These are time based codes. The initial code is used to report the first 30 minutes of intra-service time with each additional 15 minutes of intra-service time being reported by reporting additional codes.