Gastroenterology Coding Alert

Question: I want to bill conscious sedation. Which code should I use for this, and will carriers pay for it?

GAC Subscriber

Answer: Conscious sedation is a sticky issue for coders, considering that insurance coverage of this service is sporadic at best. However, there are certain guidelines to follow when attempting to get payment for conscious sedation. You should always ask the carrier for its policy on coverage for this service.

Conscious sedation (99141-99142) is "sedation with or without analgesia [and] is used to achieve a medically controlled state of depressed consciousness while maintaining the patient's airway, protective reflexes and ability to respond to stimulation or verbal commands," according to CPT. In the past, insurance carriers have limited coverage of this service to anesthesiologists or nurse anesthetists. These conscious sedation codes, however, allow other physicians to report this service.

Use 99141 to report sedation with or without analgesia; intravenous, intramuscular or inhalation, and use 99142 to report sedation with or without analgesia; oral, rectal and/or intranasal. Remember that conscious sedation includes three services:

Performance and documentation of presedation and postsedation evaluations of patient

Administration of the sedation or analgesic agent

Monitoring of cardiorespiratory function.

Also, note that these codes are exempt from use of modifier -51 (Multiple procedures). Codes for pulse oximetry (94760-94762) may not be reported with these conscious sedation codes because they are inclusive components of the sedation procedure.

Conscious sedation codes can be used in conjunction with codes for procedures that commonly include a provision for conscious sedation. You simply need to make sure that the "sedation be administered by the physician performing the procedure and that an independent trained observer by present to assist the physician in monitoring the patient's level of consciousness and physiologic status," according to CPT guidelines. If the conscious sedation is administered by someone other than the physician, the anesthesia codes need to be used.

The issue of coverage, however, is an entirely different story. Medicare refuses to pay for conscious sedation, assuming that the service is bundled into the primary procedure. When dealing with a Medicare patient, only bill for the procedure and the sedation drug, not the conscious sedation service. For private carriers, code for the sedation procedure. Some private carriers pay, but others still refuse. It is best to ask the provider before billing.