ED Coding and Reimbursement Alert

It seems too good to be true you can report an anesthesia code for conscious sedation administered by an emergency physician. Under certain circumstances, the substitution is allowed, though you should employ it with caution.

Conscious sedation is a medically controlled state of depressed consciousness, during which the patient maintains control over the airway and can usually respond to verbal commands, says Jan Loomis, director of coding and documentation at TeamHealth West, Pleasanton, Calif.

But for anesthesia services, the physician may actually control the patient's airway, she says. There is a spectrum of potential consciousness states for anesthesia. For example, many cystoscopies are done with intravenous Versed, and the patient is awake and able to have a conversation with the anesthesiologist. Frequently with these lighter forms of anesthesia, there is an ongoing verbal exchange between the anesthesiologist and the patient regarding comfort.

You should report an anesthesia code if an emergency department physician administered conscious sedation for another physician performing surgery. According to a published comment by the American Medical Association: "If an anesthesiologist or other physician is administering the conscious sedation [for a physician performing the surgical procedure], then the appropriate code from the anesthesia section (00100-01999) should be reported by the other physician."

You should report the conscious sedation codes, 99141 (Sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation) or 99142 (... oral, rectal and/or intranasal) for a physician who also provides the surgical procedure.

But it would be inappropriate to use the conscious sedation codes in the case of one physician assisting the other performing the procedure, Loomis says.

More opportunities to employ anesthesia instead of conscious sedation codes mean more reimbursement. Medicare and many payers that follow Medicare do not pay for conscious sedation, Loomis says. The service is considered bundled into the surgical procedure, she explains.

So, assigning an anesthesia code can mean additional reimbursement. For example, a very nervous 10-year-old female presents with an infected pilonidal cyst. One physician performs the incision-and-drainage procedure. Due to the depth of sedation required for the patient with Versed and fentanyl, a second emergency department physician provides the anesthesia service. You would report the incision and drainage with 10080* (Incision and drainage of pilonidal cyst; simple) or 10081 (... complicated), and the additional anesthesia service with 00902 (Anesthesia for; anorectal procedure) for the 10080 drainage of a pilonidal cyst.

But some things never change: Conscious sedation and anesthesia codes "pose reimbursement problems," Loomis says. Be prepared for denials, even though experts forecast payment for anesthesia when an assisting physician is administering conscious sedation in the ED.

The "main problem" with assigning anesthesia codes to conscious sedation services is that the emergency department place of service (23) is a "mismatch" for them, Loomis warns. Anesthesia codes usually apply to OR (inpatient) services, in which the patient is under general anesthesia, Loomis says.

"I suspect this is why most carriers deny the service," she adds.

Whenever you apply conscious sedation codes, remember these additional tips:

1. Meperidine (Demerol) and morphine, applied alone, do not constitute conscious sedation, although they may be used in addition to midazolam (Versed) or ketamine in the service, Loomis says.

2. When reporting codes for orthopedic services whose description includes "with" or "without anesthesia," you should select "without anesthesia" when billing conscious sedation, Loomis says. The term "with anesthesia" applies to services provided in the OR, not the emergency department.

Katie Cianciolo, RHIA, CCS, CCS-P, picks out the following tips:

3. Do not report pulse oximetry separately.

4. An independent trained observer must have been present to report conscious sedation.

5. Do not report conscious sedation with anesthesia.

6. Do not use modifier -47 (Anesthesia by surgeon) with conscious sedation codes. Of note, this modifier would rarely be used in the ED because it is usually limited to regional and general anesthesia and is not recognized by Medicare.

7. Report conscious sedation, when applicable, to any CPT code. Conscious sedation is not restricted to any CPT code, Cianciolo says.

Whenever you apply anesthesia codes, remember these additional tips:

As of Jan. 1, 2002, anesthesia codes require a patient status modifier. Remind physicians to document the patient's condition in the record so you can append the appropriate modifier and potentially gain additional reimbursement.

The required modifiers 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.

Do not append these modifiers for conscious sedation codes. In addition, many payers recognize qualifying-circumstance codes, which can also bolster reimbursement.

For any appropriately documented anesthesia service, find the appropriate anesthesia code representing that specific CPT procedure and then consider the number of time units. Most payers recognize a 15-minute interval, and most EDs using anesthesia codes report a time unit of 1, but if anesthesia services go longer, additional time units can lead to increased reimbursement.