ED Coding and Reimbursement Alert

Make sure your doctor isn't doing someone else's dirty work--for free

Because emergency physicians are credentialed to perform conscious sedation, they regularly receive requests for this service on behalf of other physicians, such as plastic surgeons and orthopedists. Here's how to decide whether to report conscious sedation, anesthesia, or an E/M service when your group chooses to accommodate these requests.

Don't Report CS Alone

You can't report conscious sedation codes (99141-99142) unless the emergency department (ED) physician is performing both the sedation and the associated procedure. But this won't be the case if a non-ED physician wants the sedation for a procedure he plans on performing. Even when the ED physician does perform both the sedation and the procedure, you won't receive reimbursement from many carriers.

This is a payer-specific payment issue, but there are some possible alternatives if another code accurately describes the service you provided--check with your insurer.

No E/M, No Sedation

To administer conscious sedation, the physician needs to give the patient a thorough evaluation. -The ED physician shouldn't be giving conscious sedation without a workup,- says Sharon Clement, CPC, business manager of the ED physician group at the Norwalk Hospital Emergency Department in Norwalk, Conn.

Because the doctor has to perform this service, you can charge for the appropriate E/M level, she says. Her practice doesn't usually get reimbursed for 99141 (Sedation with or without analgesia [conscious sedation]; intravenous, intramuscular, or inhalation), but they do receive payment for the E/M service.
 
-The evaluation for a new patient in the ED, with the risk associated with conscious sedation, is not a problem-focused visit--it's a higher level,- she says.

The patients receiving conscious sedation are ED patients whom the physician is usually treating for an illness or injury that then requires a procedure, says Michael A. Granovsky, MD, CPC, FACEP, VP of MRSI, an ED billing and coding company in Stoneham, Mass.

-In addition to the E/M work that went into diagnosing the specific problem, the ED physician must expand the amount of history and physical exam performed beyond an isolated area in order to safely sedate the patient. Furthermore, the sedation process itself involves parenteral controlled substances, which captures high risk under management options elected,- Granovsky says.
 
So, if you have the appropriate documentation, you may be able to bill 99284 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: a detailed history, a detailed examination, and medical decision-making of moderate complexity) or 99285 (-which requires these three key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: a comprehensive history, a comprehensive examination, and medical decision-making of high complexity) for these services.

Smart idea: If you-re just going to bill for the E/M service and not the conscious sedation, you can create a -no charge- item number, and report the sedation services for statistical purposes only, Clement says.

Know What to Bill

These strategies work if the physician performs the services as part of an ED encounter. But the tough situation is when the doctor leaves the ED to provide conscious sedation in another department of the hospital--such as radiology--and the patient has a non-ED classification, Granovsky says.

Option: Have the non-ED physician make a written request for a consultation from the ED physician, says Martin I. Herman, MD, FAAP, FACEP, CMC, professor of pediatrics at the University of Tennessee Health Sciences Center College of Medicine and member of the pediatric emergency medical staff at Lebonheur Children's Medical Center in Memphis, Tenn.

Then, the ED physician can perform a history and physical exam, and at least bill for the E/M code. If the ED physician also performs the procedural sedation, you can bill for monitored anesthesia care (MAC) using the anesthesia codes, Herman says. For example, if the physician sedates the patient for fracture treatment of the foot, you could report 01462 (Anesthesia for all closed procedures on lower leg, ankle, and foot).

If you are going to use the consult codes, remember that the requirements for a consult include a written request, a formal written report, and a return of care back to the original physician.

-Most of the time, we will only bill the MAC and use the history and physical as part of the presedation assessment,- he says. But -sometimes, we may choose to bill it as a consultation instead of MAC.- Having the written request from the non-ED doctor allows for this possibility.

Although it is often difficult to get reimbursement for anesthesia services performed by ED physicians, many pediatric ED groups have successfully gone to payers prospectively to get ED physicians credentialed for these services.