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 the patient won't tolerate treatment well without sedation.

With a nurse present for continuous monitoring, the physician gives the patient 2 mg of Dilaudid and 2 mg of Versed IV. This makes the patient sleepy but responsive to commands. The physician then incises, drains and packs the abscess. The entire procedure takes 20 minutes.

In this scenario, you should code for moderate sedation. On the claim:

- report 10080 (Incision and drainage of pilonidal cyst; simple) for the abscess drainage.

- report 99283 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and medical decision-making of moderate complexity) for the E/M service.

- attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99283 to show that the drainage and E/M were separate services.

- report 99144 for the sedation.

- link 685.0 (Pilonidal cyst; with abscess) to 10080, 99283 and 99144 to prove medical necessity for these procedures.

2-Physician Encounters Call for Different Set of Sedation Codes

When a physician administers conscious sedation on a patient, he might ask another physician to oversee the sedation while he provides the service (or performs the procedure). When this occurs, Tereba says, you should choose from the following codes:

- 99148 -- Moderate sedation services (other than those services described by codes 00100-01999), provided by a physician other than the healthcare professional performing the diagnostic or therapeutic service that the sedation supports; younger than 5 years of age, first 30 minutes intra-service time

-  99149 -- ... age 5 years or older, first 30 minutes intra-service time

-  +99150 -- ... each additional 15 minutes intra-service time (list separately in addition to code for primary service).
 
Check out this example from LaFleur: A 4-year-old patient presents with an arm injury that the ED physician diagnoses as a slightly angulated fracture of the distal radius. An orthopedist is brought in to perform the reduction, and she asks the ED physician to provide the sedation. The ED physician gives the patient oral narcotics and administers nitrous oxide by mask when the sedation team is ready.
 
With the ED physician monitoring the sedation, the orthopedist reduces the fracture and applies a cast. Total encounter time is 18 minutes. On this claim, the ED should choose a sedation code that reflects the involvement of both physicians.

On this claim, LaFleur recommends that you:

- report 99283 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and medical decision-making of moderate complexity) for the E/M service.

- attach modifier 25 to 99283 to show that the E/M and sedation were separate services.

- report 99148 for the sedation.

- attach 813.42 (Fracture of radius and ulna; other fractures of distal end of radius [alone]) to 99283 and 99148 to represent the patient's fracture.

Payment alert: LaFleur reports more success getting paid for the 99148-99150 codes than the 99143-99145 codes. -Some Medicare carriers are paying for 99148-99150, and many Blue Cross-Blue Shield carriers are paying on some of these codes,- he says.

Leave Sedation Codes off -Targeted- Procedures

Coders who are considering a conscious sedation code should observe one important restriction: If the code for the procedure has a -8- sign next to it in the CPT book, you cannot report conscious sedation along with the code unless two providers are involved, Granovsky says. If you report a conscious sedation code from the single physician set of 99143-99145 along with a -targeted- code, you-ll receive a denial.

Consider this example:

The ED physician inserts a chest tube in a patient with a spontaneous pneumothorax. The physician sedates the patient with Versed and Fentanyl. On the claim, you should only report 32020 (Tube thoracostomy with or without water seal [e.g., for abscess, hemothorax, empyema] [separate procedure])

(Note: There is a list of -targeted- codes in Appendix G of CPT 2007, under the heading -Summary of CPT Codes That Include Moderate [Conscious] Sedation.-)

Exception: There is one scenario in which insurers allow you to report a conscious sedation code in addition to a -targeted- code. In the ED setting, if one physician performs the procedure and a second physician oversees the sedation, you can report 99148-99150 along with an Appendix G-listed procedure code, Granovsky says.

However, encounters of this sort are not that common, LaFleur says. -CPT suggests that needing a second physician for any of the -targeted- procedures is unusual,- he says.