ED Coding and Reimbursement Alert

In the March issue of ED Coding Alert we covered the reporting of conscious sedation performed in the ED (Correctly Code for Conscious Sedation in the ED, pages 17-19). Since that issue, we have received several additional reader questions on this topic. For example, how should you report conscious sedation if it is performed by a second physician and not the physician performing the main procedure? And, when is conscious sedation considered bundled into the code for the procedure?

First, conscious sedation codes (99141-99142) should not be used if the sedation is performed by another physician (i.e., one physician performing the surgical procedure and another physician solely dedicated to performing the conscious sedation), says John Turner, MD, medical director of documentation and coding compliance for Knoxville, TN-based TeamHealth, Inc. an multi-state emergency physician practice management group.

CPT states that if conscious sedation is administered in support of a procedure provided by another physician then the anesthesia codes should be used, Turner explains.

These codes (00100-01444) are used for any anesthetic administered by a physician, not just for general anesthesia that is administered in an operating room, the physician adds.

The anesthesia code is selected based on the part of the body that is undergoing a surgical procedure. For example, conscious sedation performed by another physician in support of a facial laceration repair would be reported using 00100 (anesthesia for procedures on integumetary system of head and/or salivary glands, including biopsy; not otherwise specified).

Procedure Codes That Include Anesthesia

However, anesthesia codes and conscious sedation codes should not be used in conjunction with a procedure code with a CPT definition that states requiring anesthesia, explains Pat Moore, vice president of reimbursement for Healthcare Business Resources, Inc., an emergency medicine billing company in Durham, NC.

For example, CPT lists two codes for closed treatment of shoulder dislocation, with manipulation. The definition for the first code, 23650, states without anesthesia. The next code, 23655, is for the same procedure, but the definition states requiring anesthesia.

The second code indicates the administration of anesthesia, so conscious sedation would not be separately billable, she states.

For third-party payers that do not recognize the conscious sedation codes, it might be preferable for coders to choose a code for the procedure that included the statement requiring anesthesia, because the reimbursement would normally be higher than for the corresponding without anesthesia codes, Moore advised readers in the previous ECA article.

Since publication of that issue, she has received numerous comments from ED coders who believed that the requiring anesthesia codes should only be reported for general anesthesia that is delivered in a hospital operating room.

And, the January 1999 CPT Assistant contains an answer to a reader question indicating that the descriptor requiring anesthesia means requiring general anesthesia. However, both Moore and Turner agree that this is not always the case.

Anesthesia listed in the CPT [definition] can mean local or regional anesthesia or conscious sedation, states Turner, who is also a member of the Coding and Nomenclature Advisory Committee (CNAC) for the American College of Emergency Physicians. Anesthesia can even represent something as minor as a ring block on a finger.

Moore finds additional support for her opinion in the fact that CPT definitions indicate when only general anesthesia is included in the code.
Some codes specifically state requiring general anesthesia or regional anesthesia, she states.
For instance, code 27266 is the code for closed treatment of post hip arthroplasty dislocation requiring regional or general anesthesia.CPT would not specify regional or general in some definitions if the term anesthesia were supposed to represent only general anesthesia, Moore believes.

In addition, the anesthesia guidelines listed in the CPT manual state that anesthesia services may include but are not limited to general, regional, supplementation of local anesthesia, or other supportive services.

When is Conscious Sedation Bundled into the Procedure?

According to the CPT manual, the only codes not eligible to be reported in addition to conscious sedation are 94760-94762 (for pulse oximetry monitoring).

Note: By CPT definition, performance of conscious sedation requires pulse oximetry, cardiorespiratory and blood pressure monitoring by an independent trained observer.

However, some third-party payers do consider performance of conscious sedation to be included in the procedure code, although most physicians dispute the clinical validity of this policy. For example, Medicare, although it has assigned relative value units to the codes in its fee schedule, does not pay for conscious sedation.

We have also found that some of the Medicaid and Blue Shield carriers bundle it into the procedure code as well, says Moore, whose company bills for ED physician groups in several states.

There is no hard and fast way to tell whether a payer will pay for conscious sedation or not, advises Moore. HBR tests new payers by sending claims with the procedure coded separately, according to CPT guidelines, the first time they submit a conscious sedation claim to that carrier. Then, if the code is denied, they contact the payer to find out why.

Dont just assume that they consider it bundled, she emphasizes. Conscious sedation codes are relatively new CPT codes and some payers just dont have up-to-date computer claim-processing systems.

It takes some payers a little longer to add new procedures, Moore says. Conscious sedation was a new code last year. You might have billed it toward the beginning of the year last year and had the code rejected, but by the end of the year they might start to pay it.

If you contact your payer and find that they do not bundle it, but that their system is not set up to recognize the codes, you can file an appeal.

You shouldnt just exclude the codes arbitrarily because you get a denial, she adds. I like to wait about six months and try again, or stay in contact with the provider representative to find out whether they start paying for it.

Billing an E/M Level

As Moore advised in the previous article, ED coderswith proper documentation availablecan report an E/M code in order to get reimbursed for the significant evaluation and monitoring required for the performance of conscious sedation.

We are in the emergency department and there are no established patients. Therefore, we use the [emergency department] E/M codes [99281-99285] to cover the monitoring and any testing that has to be donerechecks and taking a medical historyin order to perform conscious sedation, she says.

Moores coders use the physician documentation of the history, evaluation, medical decision-making and performance of the monitoring (pulse oximetry, blood pressure, cardiac monitoring) to determine an appropriate E/M level.

You have to have the necessary documentation.You have to meet all of the normal requirements, she emphasizes. Usually you should have enough for detailed history, detailed exam and decision-making of moderate complexity (99284). Conscious sedation does meet a high level of service when you count in the monitoring and pulse ox and add in the repeat exams and history that the physician usually obtains because he or she wants to be sure the patient does not have any other medical problems that they are not aware of.