Gastroenterology Coding Alert

Question: Will Medicare pay for conscious sedation for colonoscopies and esophagogastroduodenoscopies (EGD) done in an outpatient setting?

Debbie Swafford, Office Manager
Thomas Swafford, MD
Stillwater, Okla.

Answer: In Get Reimbursed for Conscious Sedation From Private Insurers (December 1999 Gastroenterology Coding Alert, p. 29), it was reported that Medicare generally does not reimburse gastroenterologists for the administration of conscious sedation because it is considered a standard component of most endoscopies.

This concept of a global fee also applies to procedures done by gastroenterologists in a non-office setting, such as an endoscopy center or other outpatient setting. The gastroenterologists are billing for procedures done in an endoscopy center with the same CPT code that they would use in an office setting, says Kathy Anderson, RN, director of nursing and plant manager of the Indianapolis Endoscopy Center, an ambulatory surgical center serving four gastroenterologists. The administration of anesthesia is already considered a component of the professional fee.

Conscious sedation also is considered a component of the facility fee that the endoscopy center bills Medicare and cannot be billed separately, Anderson notes. Anesthesia, drugs and supplies are generally included already in the facility fee, she explains.

You might have better luck getting reimbursement for conscious sedation from private insurers, however. Many commercial insurance companies do honor these claims. When billing for this procedure, the main endoscopy should be listed first because it has higher relative value units, followed by the code 99141 (sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation).