General Surgery Coding Alert

Question: Especially when dealing with young children, our surgeon will administer conscious sedation during difficult procedures such as endoscopic exams. How should we report this? May we use anesthesia codes such as 01922?

Texas Subscriber

Answer: No, you should not use 01922 (Anesthesia for non-invasive imaging or radiation therapy) or other general anesthesia codes to report conscious sedation.
 
You should report 99141 (Sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation) or 99142 (... oral, rectal and/or intranasal), as appropriate, to report conscious sedation when the surgeon also performs the primary procedure (such as colonoscopy or other endoscopic procedure). Conscious sedation includes performance and documentation of pre- and postsedation evaluations, administration of sedation and/or analgesic agent(s) and monitoring of cardiorespiratory function (i.e., pulse oximetry, cardiorespiratory monitor, and blood pressure).
 
The same physician who performs the primary procedure normally provides conscious sedation, although CPT does specify that an "independent trained observer" be present to assist the physician in monitoring the patient's level of consciousness and physiological status. There is no provision for separate payment of the observer, and the observer need not be another physician.
 
The statement in CPT specifying "If the sedation with or without analgesia is administered in support of a procedure provided by another physician, see the anesthesia section" is directed specifically toward anesthesiologists.
 
If the surgeon provides conscious sedation in support of another physician, the surgeon must consider local licensing rules and regulations and scope-of-practice laws before reporting an anesthesia code.