Gastroenterology Coding Alert

Look to Appendix G for a complete list of services that include CS

Physician offices have struggled for years to determine exactly when they can report conscious (or moderate) sedation. CPT 2006 now provides more explicit guidelines for conscious sedation, along with six new codes to describe the procedure.

As a rule, if your physician provides both a procedure and conscious sedation, you won't report the CS separately.

Target the -Bull's Eye-

If you see a procedure code in the CPT manual with a -dot inside a circle- (which looks a lot like a target -bull's eye-) next to it, you-ll know that you shouldn't report CS separately with that procedure, says Michael A. Granovsky, MD, CPC, FACEP, vice president of Medical Reimbursement Systems, an ED billing company in Stoneham, Mass.

Instructions contained in Appendix G of CPT explain that certain codes include conscious sedation -as an inherent part of providing the procedure. These codes are identified in the CPT codebook with [the target] symbol.- The instructions go on to note that if the same physician provides a -targeted- code and the CS, -it is not appropriate - to report both the service and the sedation codes 99143-99145.-

Targeted codes include many endoscopic procedures common in GI practice, including esophagoscopy (43200-43232), upper GI endoscopy (43234-43259), proctosigmoidoscopy (45303-45327) and colonoscopy (45355-45392) and others.

Just the facts: You can't bill separately for 99143, 99144 or 99145 (see -Get to Know Your New Conscious Sedation Codes- later in this issue for complete definitions of the new CS codes) if your gastroenterologist provides both a targeted service (for instance, 43234, Upper gastro-intestinal endoscopy, simple primary examination [e.g., with small-diameter flexible endoscope] [separate procedure]) and CS.

You Still Need an Independent Observer

As in years past, if the primary physician provides CS, you should have an independent, trained observer on hand to help monitor the patient.

Specifically, documentation should provide proof of the observer's presence and note that the observer monitored the patient's cardiorespiratory functions (pulse oximetry, cardiorespiratory monitor and blood pressure) for the duration of the CS. In addition, the physician documentation should record a presedation and post-sedation assessment, Granovsky says.

Frequently, this documentation is recorded -using an institutional CS flow sheet that is filled out by the nurse for the bedside vital signs and co-signed by the doctor,- Granovsky says.
 
Setting Matters for 99148-99150

You may be able to report 99148-99150 for CS during a targeted procedure, says Kelly Dennis, CPC, ACS-AP, president of Perfect Office Solutions Inc. in Leesberg, Fla., but the service must meet two requirements:

1. As required by the code descriptors, a second physician (not the physician providing the service that supports the CS) must provide the CS.

2. The targeted procedure supporting the CS and the CS must take place in a facility setting (such as a hospital, outpatient hospital/ambulatory surgery center, or skilled nursing facility).

Not in the office: You cannot bill for moderate sedation in the physician's office or other nonfacility setting, even if a second (different) physician provides the CS while the primary physician renders the targeted service that supports the CS, according to newly added CPT language.

Lack of CS Won't Mean 52

Although targeted procedures such as colonoscopy include CS when provided by the same physician providing the procedure that supports the CS (or when a second physician provides the CS in a nonfacility setting), this does not mean that your reimbursement will fall if you do not provide CS during a targeted procedure. CPT specifically states that you need not append modifier 52 (Reduced services), for example, -when the patient does not require sedation.-

In other words: You will not gain extra reimbursement for providing CS in most cases, but neither will your payment decrease if you don't provide CS.