ED Coding and Reimbursement Alert

Good news: Some insurers are now reimbursing sedation codes, experts say When your ED physician performs moderate (or conscious) sedation on a patient, there may be some reluctance to report the sedation code to the insurer. After all, many carriers are still not reimbursing for the service, which CPT anointed with a new code set in 2006.

Leaving these codes off the claim could be a mistake, however, because some insurers have started paying for moderate sedation, says Robert LaFleur, MD, FACEP, of Medical Management Specialists in Grand Rapids, Mich.

-Reimbursement for moderate sedation has been spotty,- he concedes. But LaFleur goes on to say that some payers have started paying for certain types of moderate sedation.

Additionally, Medicare designated these codes as -carrier-priced- in order to gather information for utilization and proper pricing.
 
-Many Medicare carriers are beginning to recognize moderate sedation, says Michael Granovsky, MD, CPC, FACEP, president of MRSI, an ED coding and billing company in Woburn, Mass. So while you may not get paid every time you report moderate sedation, it is a good idea to include it on the claim when you-re allowed to. The more times an insurer sees moderate sedation codes on claims, the more likely it will be to consider paying for the service in future policy decisions.

Best bet: Get into the habit of coding for moderate sedation. Check out this primer on the ins and outs of moderate sedation coding.

Use 99143-99145 When Physician Performs Procedure, Sedation There are two sets of moderate sedation codes, which are separated based on the number of physicians involved.
 
You-ll choose from one of these codes when the same physician performs the sedation and the procedure (or service), says Cheryl Tereba, manger of revenue recovery for UMass Memorial Healthcare's Department of Emergency Medicine in Worcester:

- 99143 (Moderate sedation services [other than those services described by codes 00100-01999] provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status: younger than 5 years of age, first 30 minutes intra-service time) if the patient is under 5 years old.

- 99144 (... age 5 years or older, first 30 minutes intra-service time) if the patient is 5 years or older.

-  +99145 (... each additional 15 minutes intra-service time [list separately in addition to code for primary service]) for each additional 15 minutes of sedation beyond the first half-hour. To illustrate proper use of these codes, LaFleur offers this example:

A 30-year-old patient presents with a pilonidal abscess that requires drainage. The area is tender, and the patient is apprehensive. After conducting the initial history and exam, the physician decides that [...]