General Surgery Coding Alert

Question: I have read that conscious sedation by a physician performing an endoscopy is not covered, but I've also been told that I can have patients sign a waiver making them responsible for payment. Which is correct? Can we receive payment for conscious sedation with endoscopy?

Oregon Subscriber

Answer: Medicare and most private payers do not reimburse for conscious sedation (99141, Sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation; and 99142, ... oral, rectal and/or intranasal), regardless of circumstances, and bundle the service to all surgical/diagnostic procedures. Because the service is bundled, or included (as opposed to simply "uncovered"), you may not ask the patient to sign an advance beneficiary notice (ABN) or other waiver and collect separate payment. This is double-billing and is punishable as a form of fraud. By the same logic, you cannot ask a patient to sign a waiver to receive separate payment for a component procedure bundled by the national Correct Coding Initiative (CCI).

Some form of sedation is commonplace for patients receiving upper or lower gastrointestinal endoscopies. Except in extreme circumstances (for example, a medically unstable patient), sedation and monitoring are the responsibility of the surgeon and his or her team, and Medicare would deem the presence of an anesthesiologist unnecessary and, therefore, not separately payable. In those cases when an anesthesiologist's services are required, be sure to note separately the pre-existing medical condition (such as uncontrolled hypertension, acute asthma, coma, etc.) that prompted the need for the anesthesiologist.