Gastroenterology Coding Alert

In general, you cant bill conscious sedation (99141, 99142) with endoscopic procedures. Thats because this service is bundled into endoscopies. Conscious sedation has been part of endoscopy since it began being performed, explains Glenn D. Littenberg, MD, who is a member of the American Society of Internal Medicines Committee on Payment and Coding and a member of the AMAs CPT Editorial Panel. This means when you bill for a colonoscopy, for example, the relative value units (RVUs) for conscious sedation are already calculated into its fee, says Littenberg, a gastroenterologist practicing in Pasadena, CA. Virtually all payers consider conscious sedation to be bundled into the endoscopy.

Noting that the conscious sedation codes were created mainly for children, to be used in procedures which would not normally require sedation in adults (such as the repair of facial lacerations), Littenberg says most payersand in particular Medicarewill deny 99141 or 99142 if you file it with an endoscopic procedure.

Sedation With or Without Analgesia (Conscious Sedation) Sedation with or without analgesia (conscious sedation) is used to achieve a medically controlled state of depressed consciousness while maintaining the patients airway, protective reflexes and ability to respond to stimulation or verbal commands. Conscious sedation includes performance and documentation of pre- and post-sedation 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). The use of these codes requires the presence of an independent trained observer to assist the physician in monitoring the patients level of consciousness and physiological status. 99141: Sedation with or without analgesia (conscious sedation); intravenous, intramuscular or inhalation 99142: Sedation with or without analgesia (conscious sedation); oral, rectal and/or intranasal

Modifier -22 Works Better Than -59
The one possible exception to this rule is flexible sigmoidoscopy (45330), a procedure which does not normally call for sedation, says Littenberg. If you really had unusual circumstances, and you needed to use conscious sedation, you could put a -22 modifier on the procedure, he explains. The -22 modifier is defined in CPT as being for unusual procedural services. That means that the service you provide is greater than that usually required for the listed procedure. You will also need to submit a narrative report explaining why the sedation was necessary, says Littenberg.

Alternatively, you could place modifier -59 on the conscious sedation code, he continues. Modifier -59 indicates a distinct procedural service which is performed on the same day as another service. However, modifier -59 should be used as a last resort, and if any other modifier is more appropriate, you should use it. Littenberg adds that it would probably be better to use a -22 modifier on the sigmoidoscopy, and add the conscious sedation code.

So the ideal way to code a flexible sigmoidoscopy done with conscious sedation is 45330-22 on the first line, and 99141 (if the sedation is administered by injection or inhalation) on the second line.