Gastroenterology Coding Alert

Although Medicare usually does not reimburse gastroenterologists for the administration of conscious sedation, many private insurance companies will. About 60 percent of the time, we will get reimbursement from a private insurer, says Linda Parks, MA, CPC, lead coder at Atlanta Gastroenterology Associates, a 21-physician practice. HMOs are among those that frequently dont pay, however, she notes.

Conscious sedation (99141) 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 command, according to the CPT. Its administered by the gastroenterologist through an intravenous injection of a sedative such as Demerol or Versed, explains Parks, who adds that the use of a local anesthetic such as Lidocane is not considered conscious sedation.

Medicare does not reimburse separately for conscious sedation because it considers the administration to be a standard component of most endoscopic procedures, which means that the relative value units (RVUs) for conscious sedation are already calculated in the procedures allowed reimbursement.

Although Medicare doesnt reimburse for the administration of conscious sedation, it will pay for drugs such as Demerol (HCPCS code J2175) or Versed (HCPCS code J2250) that are used to sedate the patient, adds Terry Fletcher, CPC, CCS-P, a healthcare coding consultant in Laguna Beach, CA. The HCPCS code for each sedative used should be added to the claim, she says.

Coding for a Private Payer

To bill a private payer for administering conscious sedation, Parks advises that gastroenterologists list the code for the procedure performed first because it has the higher RVU. That should be followed by code 99141 (sedation with or without analgesia; intravenous, intramuscular or inhalation). The same ICD-9 diagnosis code should be used with both CPT codes.

CPT also requires the performance and documentation of pre- and postsedation evaluations of the patient, and the presence of an independent trained observer to assist the physician in monitoring the patients level of consciousness and physiological status. According to Parks, both of these requirements usually are met by having a nurse monitor functions such as the patients pulse oximetry, blood pressure and cardiorespiratory rates. The monitored results should be included in the operative report.

Dont Add Codes for Secondary Payers

I know Medicare doesnt pay for conscious sedation, but other private insurers will. Is there a way to fill out the claim so you wont be flagged by Medicare but will receive reimbursement from the secondary payer? asks Denine Hallgarth, office manager at Madison Internal Medicine, a 40-physician, multispecialty practice in Hanover, IN, with two gastroenterologists.

If Medicare doesnt reimburse for a procedure such as conscious sedation, then private insurers who are secondary payers wont reimburse for it either, even if they would as a primary payer, says Fletcher, who cautions against revising claims that go to secondary payers. It is considered fraud to add codes to claims to secondary payers.

Getting reimbursement from private insurance companies for the administration of conscious sedation is largely a matter of understanding the policies of each payer. Its pretty straightforward, says Parks, once you get to know who will pay for what.