ED Coding and Reimbursement Alert

Providing services and getting paid don't always coincide

If you can't decide when to bill an anesthesia code, when to bill conscious sedation, and when to skip them both, read this to find clear answers in the coding fog. Walk the Thin Line As more and more sophisticated sedation techniques evolve, the line dividing anesthesia from conscious sedation becomes blurry. Count on these giveaways to signal conscious sedation:  The patient can breathe on his own, without assistance.
  The patient can respond to either verbal or physical stimuli, or both.
  The physician has an independently trained observer to assist him in monitoring the patient. Beware: Even if the ED physician has provided perfect documentation for you to bill a conscious sedation code, be aware that depending on the payer, you may not receive reimbursement, says Robert La Fleur, MD, FACEP, president of Medical Management Specialists in Grand Rapids, Mich. Talk to your carrier to find out.

You should also know your payer because Medicare assigns CPT codes 99141-99142 "B" status, because they think payment is included in the payment for other services. And although these codes are assigned relative value units (RVUs), those RVUs are not used for Medicare payment. Private payers have varying policies. Know Which Doctor Does What If the ED physician has provided proper documentation that he performed both the sedation and the procedure, reporting 99141 (Sedation with or without analgesia [conscious sedation]; intravenous, intra-muscular or inhalation) and 99142 (... oral, rectal and/or intranasal) is appropriate. According to the American College of Emergency Physicians (ACEP), "The conscious sedation (sedation with or without analgesia) codes are for use only by the same physician who is performing the diagnostic, therapeutic, or invasive procedure."

But for anesthesia codes, the opposite is true: Different physicians must perform the procedure and the sedation. If, for instance, the orthopedist performs a fracture reduction while the ED physician provides sedation in support of the procedure, the ED physician should bill for his services using the appropriate anesthesia codes. Be Careful With 'General Anesthesia' Your best bet is usually to avoid the CPT codes that include the phrase "with anesthesia," because it indicates general anesthesia that an ED physician wouldn't ordinarily provide. The American Medical Association's Department of Coding and Nomenclature staff has clarified that the phrase "with anesthesia" means the patient is in the operating room under general anesthesia and that you should not use CPT codes carrying that descriptor in the ED.

If the sedation is deep - the patient has minimal response to pain and no ability to really protect his airway - a physician should be at the bedside monitoring the patient's airway and other vital signs, says Martin I. Herman, MD, FAAP, FACEP, medical director [...]