General Surgery Coding Alert

CMS has given the green light for Medicare carriers to pay for moderate sedation codes 99143-99145, according to a recent Medlearn Matters article (#MM5681, released Aug. 17). Codes 99143-99145 describe situations in which the same physician both administers the moderate sedation and performs the primary procedure.

Until this time, many carriers have covered only moderate sedation codes 99148-99150, during which one physician performs the primary procedure and another, separate physician sedates the patient.

As of Oct. 1, "If the physician performing the procedure also provides moderate sedation for the procedure, then payment may be made for conscious sedation consistent with CPT guidelines," says Transmittal R1316CP (Change Request 5618), which was released in early August. CMS will also revise the Medicare Claims Processing Manual "to be consistent with the pricing of the conscious sedation codes under the Medicare physician fee schedule payment system and CPT coding guidelines," the Medlearn Matters article says.

The new language is a "positive sign" and may show that Medicare is responding to providers- letters in support of moderate sedation, says David McKenzie, CAE reimbursement director with the American College of Emergency Medicine.

Good news: "Carriers now-have the OK that it would be acceptable from Medicare to process these codes-for payment," says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver.

Bad news: CMS still gives "no guidance at all as to payment," says Margaret Loftus, a coder with Stanford Hospital and Clinics in Palo Alto, Calif. "The codes are carrier-priced, which means every Medicare carrier is free to value them as they will." And as long as these codes are "Status C," carriers have discretion on whether to pay for them. Most payers probably won-t.

The "best-case scenario" is that Medicare may actually add relative value units (RVUs) to all of the moderate sedation codes in 2008, Hammer adds.

When reporting moderate sedation codes, make sure your documentation specifies the level of sedation, Hammer says. The Medlearn Matters article stresses, "Physicians who both perform, and provide moderate sedation for, medical/surgical services will be paid for the conscious sedation consistent with CPT guidelines. However, physicians who perform, and provide local or minimal sedation for these procedures will not be paid separately for the sedation services" (emphasis included in the original).

Watch out: You should never report 99143-99150 with the codes listed in CPT's Appendix G because those codes include conscious sedation.

Learn more: For complete information on guidelines for reporting moderate sedation codes, see "Wake up and Learn Your New CS Codes," pp. 13-14, and "Want the Facts on Conscious Sedation? Get Them Here," pp. 12-13, of the February 2006 General Surgery Coding Alert.