Gastroenterology Coding Alert

Why can't I report the sedation? Medicare already figures the cost of the conscious sedation when it calculates the relative value units (RVUs) for 43235, according to experts. To report the sedation separately would be double-billing.
 So forget about putting a conscious sedation code on an EGD claim for a Medicare patient. There are possibilities for reimbursement from other payers, though.

Persistence Pays Off With Private Insurers

"It's a challenge" to get conscious sedation reimbursement, concedes Lois E. Curtis, CPC, insurance/billing manager for Gastroenterology Associates in Evansville, Ind. But aided by smart research techniques, Curtis and her coding colleagues were able to secure conscious sedation reimbursement from several independent payers.
 
Read on for some advice on how to find out which payers won't be numb to your conscious sedation coding  - and what your claim should contain to stand the best chance of acceptance.

First Step: Research Contracts

Start your path to private-payer reimbursement by getting copies of your individual contracts with your biggest insurers.
 
"We constantly have our [doctors] asking to bill for it during procedures. But we've found that most of our payers in Wisconsin will not pay separately for it," says Margie Pfaff, corporate compliance analyst for Medical Associates Health Centers in Wisconsin, who reached this unfortunate conclusion after checking her office's contracts with major insurers.
 
For the major private companies, Curtis' office had copies of most of the contracts on file, but you can find them online or get one from the payer if you don't have one, she says.
 
"That's what we did with our biggest payers; on most of our big network contracts, whether or not they'll pay (for conscious sedation) is spelled out. But some of those contracts can be tough to read," Curtis says.
 
If you can't find proof in the contract that the company will pay separately for conscious sedation, experts suggest calling and speaking to a representative.

Take a Chance With Smaller Companies

With smaller payers, finding a copy of your contract may be more difficult. It also may not be realistic to check every individual payer contract your office has, so in some cases you may want to consider filing a claim for conscious sedation to see if the company will pay for it.
 
"It's so tough to call each and every smaller payer, because your office may have tons of carriers," Curtis says. If you do decide to report the conscious sedation separately with an endoscopic procedure, follow this coding example:
 
Let's say the gastroenterologist performs an upper endoscopy with guidewire dilation on a patient for repair of a hiatal hernia with a stricture. You should:

 

What if the insurer denies 99141? Make note of it so no one will try reporting conscious sedation separately to that payer again.

Best Advice: Beef Up Claim With Notes

Most claims go through easier with solid documentation, and conscious sedation claims are no exception. For more on the documentation you must have before separately reporting conscious sedation with an endoscopic procedure, see "Note Every Detail to Ensure Sedation Claim Success" this issue.