Gastroenterology Coding Alert

Although Medicare does not pay for conscious sedation for colonoscopies, some private payers do. So if you fail to report the conscious sedation to insurers that will reimburse, or fail to bill the sedation drugs to all payers, you are losing out on valuable revenue.

Medicare designates conscious sedation (99141-99142) as a status B on the Medicare Fee Schedule Data Base (MFSDB), meaning the service is bundled into the primary procedure. Because the cost of conscious sedation is factored in to the relative value units (RVUs) of a colonoscopy, no separate payment will be made.

You should not list the conscious sedation code on the Medicare claim even if you plan to write off the noncovered service. The Office of the Inspector General considers repetitively billing for a bundled service fraud.

However, if the procedure is performed in a nonfacility setting, Medicare will reimburse for the supply. You should code for the colonoscopy with the appropriate code from the endoscopy series 43235-43255 or the colonoscopy series 45378-45387 and the sedation drugs, such as Versed (J2250) or Demerol (J2175), with the appropriate supply code.

For example, suppose a gastroenterologist performs an endoscopy on a Medicare patient who has upper abdominal pain. The doctor injects intramuscularly 1 mg of Versed into the patient to induce conscious sedation. After inserting the endoscope, he obtains a biopsy of the gastric mucosa.

For the endoscopy with biopsy, you should assign 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple) linked with 789.0x (Abdominal pain).

Because you are billing Medicare, you should not report the conscious sedation. "I was worried about reporting the same procedure differently from one carrier to the next," recalls Stephanie Goodfellow, billing manager at the Mid-America Gastro-Intestinal Consultants in Kansas City, Mo. "But, I called Medicare and they said [that] for noncovered items, you don't have to file a claim."

Regardless of whether a service is billed, good record-keeping requires thorough documentation. Therefore, you should document conscious sedation in the patient's record. "Enter the code in the computer with a zero dollar amount," advises Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C. "The office computer will track the service but not transmit it to the insurance company."

Next, report the Versed with J2250 (Injection, midazolam HCl, per 1 mg). In the example above, the doctor delivered 1 mg, so report J2250 once.

The Medicare claim form should read: