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Gastroenterology Coding Alert

Note Every Detail to Ensure Sedation Claim Success

Published on Wed Sep 08, 2004

If you can't prove medical necessity, sedation payment is unlikely

Getting separately reimbursed for conscious sedation during an endoscopic procedure is always a challenge - but it's nearly impossible if you submit claims without appropriate documentation to back up the medical necessity of the conscious sedation (99141, Sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation).
 
Follow this advice from Lois E. Curtis, CPC, insurance/billing manager for Gastroenterology Associates in Evansville, Ind., on filing successful conscious sedation claims.
 
For your claim to be spot-on, your documentation should include:

 

  • the operative report with medication, dose time started and time ended. Notes that read, "Conscious sedation (99141) with 1 mg Versed given" would be sufficient, for example.
     
  • documentation that proves the gastro performed conscious sedation pre-/postsedation patient evaluations.
     
  • notes showing that the physician who performed the  colonoscopy also administered the sedation.
     
  • proof that an independent, trained observer monitored the patient during the procedure.
     
  • documentation proving that the observer monitored the patient's cardiorespiratory functions (pulse oximetry, cardiorespiratory monitor and blood pressure).

    Another benefit: The documentation may also pay off if you need to appeal to get payment for conscious sedation. "We have had appeals on conscious sedation reimbursement where I had my documentation on hand, and we got them overturned quickly," Curtis says.

    Be Sure the Contract Supports Sedation

    On March 8, the three major GI societies (AGA, ASGE and ACG) issued a joint statement on sedation and endoscopy. The recommendations note that "Reimbursement for conscious sedation is included within the codes covering endoscopic procedures."  The statement reminds providers that "billing separately for conscious sedation has been targeted by the OIG as a possible fraud and abuse violation, and is not recommended."
     
    Explanation: If a carrier believes that it has paid separately for the conscious sedation in error, most provider contracts allow the carrier to deduct the overpayment from future payments to correct their mistake. The joint statement provides carriers with sufficient support to recoup payments for conscious sedation. 
     
    Solution: Get sedation approval in writing. "Because of the GI societies' statement, we only bill the conscious sedation code to those carriers that have contractually agreed to pay us for the service specifically," says Kirk Brandon, administrator for Metropolitan Gastroenterology Group in Washington, D.C.

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