ED Coding and Reimbursement Alert

Emergency department coders often say they are in a quandary about how to correctly report procedures that involve conscious sedation and anesthesia. CPT includes codes and definitions exclusively for conscious sedation, as well as procedure codes that allow for anesthesia during specific services. However, contradictory definitions of what constitutes anesthesia abound, causing confusion about when to report conscious sedation services as opposed to codes that refer to "with anesthesia." Reimbursement policies also vary wildly from payer to payer, adding to the bafflement of professional coders.

Understanding Conscious Sedation

Most clinicians and coders agree on what constitutes conscious sedation. In short, CPT defines conscious sedation as a medically controlled state of depressed consciousness while maintaining the patient's airway, protective reflexes, and ability to respond to stimulation or verbal commands. Generally speaking, conscious sedation is used when performing painful or long procedures (e.g., during laceration repair, orthopedic stabilizations, etc.). It may also be used when children or the elderly are treated, because they often have lower tolerance to pain. For coders to assign conscious sedation codes, they must ensure that the medical record includes performance and documentation of pre-, intra- and postsedation evaluations of the patient, administration of the sedation and/or analgesic agent(s), and monitoring of cardiorespiratory function (i.e., pulse oximetry, cardiorespiratory monitor, and blood pressure). Conscious sedation is an invaluable procedure in the emergency department. However, it is not anesthesia, and this has created controversy complicated by varying payer policies governing how it is paid.
 
According to Cindy McMahan, CPC, an independent coding consultant based in Albany, Wisc., conscious sedation is reported with one of two codes, depending on the method of administration:
 

99141 sedation with or without analgesia (conscious sedation); intravenous, intramuscular or inhalation

99142 ... oral, rectal and/or intranasal.

"CPT has implemented very clear coding guidelines that govern the use of the conscious sedation codes," McMahan says. "The requirements include that the sedation be administered by the physician performing the procedure, and that an independent, trained observer be present to assist the physician in monitoring the patient's level of consciousness and physiological status."
 
The definition of independent, trained observer, she adds, indicates that a designated individual, other than the performing physician, should be responsible for monitoring the patient during the procedures performed with sedation and, when appropriate, analgesia. "This individual, often a registered nurse, should be able to recognize complications, and be capable of establishing a patient airway and positive pressure ventilation," McMahan says. The observer should also maintain advanced life support skills and be prepared to summon additional assistance if necessary.
 
McMahan adds that payer policy regarding conscious sedation varies a lot. "Many insurers won't reimburse for this service," she says. "Medicare, in fact, assigns conscious sedation codes a 'B' status, which means they are bundled into whatever procedural service they are associated with and will not be paid separately from the primary service."
 
Among the analgesic (or pain-relieving) drugs categorized as agents of conscious sedation are benzodiazepines like diazepam (Valium) and midazolam (Versed), opiates like meperidine (Demerol) and fentanyl (Sublimaze), and neuroleptics like haloperidol (Haldol) and droperidol (Inapsine). Each medication elicits diverse benefits and risks in patients, and must be administered carefully.
 
Emergency physicians are also using a second classification of drugs called anesthetic induction agents more frequently. These medications, which include ketamine (Ketalar), propofol (Diprivan) and sodium thiopentone (Pentothal), offer many of the same benefits of the more commonly used drugs, with the added benefit that the patient often has no memory of the procedure. Anesthetic induction agents are considered bundled into the conscious sedation codes and are reported separately.
 
Understanding Anesthesia Codes

The term "anesthesia" is not universally understood, however. Because of clarifications from AMA staff, anesthesia is accepted to mean only the type of general anesthesia that is administered in the operating room or surgical suite, according to Caral Edelberg, CPC, CCH-P, president of Medical Resource Management in Jacksonville, Fla. This means that no service provided in the emergency department would be identified with the operative procedures including "anesthesia." However, notes in the CPT manual provide for greater latitude in defining anesthesia. In comments preceding the code descriptions for 99141 and 99142, CPT states, "If the sedation with or without analgesia (conscious sedation) is administered in support of a procedure provided by another physician, see Anesthesia section."
 
Edelberg says this has often been interpreted to mean that conscious sedation is considered "anesthesia" if given by a different physician from the physician performing the core procedure. In these cases, an anesthesia code (0010001999) would be assigned. However, these codes are not likely to be paid to the emergency physician. Likewise, a code describing an operative service that includes the anesthesia might also be appropriate. For instance, a patient presents to the ED with a dislocated shoulder. Because he is in great pain and is not cooperating with the physician's attempt to reposition the shoulder, conscious sedation (anesthesia) may be administered by another physician to relax the patient. This service would be reported with 23655 (closed treatment of shoulder dislocation, with manipulation; requiring anesthesia).
 
"In other words, an anesthesia-specific code might be most appropriate if an ED physician other than the physician performing the reduction procedure provides the appropriate monitoring of the patient, administers the conscious sedation agent(s), and is responsible for treatment of any complications of the conscious sedation," Edelberg says.
 
She notes that this approach may enhance reimburse-ment for emergency departments when a second physician administers conscious sedation in this fashion. According to the rate for physician work relative value units (RVU) listed in the 2002 Medicare RBRVS Physician Payment Schedule, the national average Medicare payment for 23655 is about $165.43. On the other hand, 23650 ( without anesthesia) is paid at a national rate of $122.71. Because Medicare does not reimburse separately for conscious sedation, no additional payments would be made under those circumstances.
 
Because interpretation of "anesthesia" may differ from payer to payer, Edelberg recommends contacting insurers to determine their guidelines for reporting these services.

Anesthesia Modifiers Now Required

Changes to CPT in 2002 will demand more communication between coders and ED physicians when anesthesia codes are assigned, says Edelberg. "CPT now requires that anesthesia claims include a 'patient-status modifier' to be considered for payment. Of course, a coder will have no way to determine that unless the physician documents the patient's condition clearly in the record." She recommends that coders remind ED physicians of the importance of this new requirement.
 
The modifiers that must be appended as of Jan. 1, 2002, are:
 P1 normal healthy patient
 P2 patient with mild systemic disease
 P3 patient with severe systemic disease
 P4 patient with severe systemic disease that is a constant threat to life
 P5 moribund patient who is not expected to survive without the operation
 P6 declared brain-dead patient whose organs are being removed for donor purposes.

These modifiers are not required when reporting conscious sedation codes.