General Surgery Coding Alert

Reporting CS with a -targeted- service puts a denial bull's eye on your claim.

If you-re not coding for the moderate sedation (also known as conscious sedation or CS) your surgeon performs during a procedure, you-re potentially costing your practice money for every procedure he uses moderate sedation for. How much depends on your payer.

"Coders shouldn't assume they cannot report the sedation," says Lisa Center, CPC, physician billing certified professional coder with Mt. Carmel Regional Medical Center in Pittsburg, Kan. "They need to check the codes to see if the code includes sedation and, depending on the setting, they might be able to use one of the conscious sedation codes." Make sure you-re not losing precious reimbursement with these expert tips on moderate sedation coding.

The moderate sedation codes are divided into two sections based on who is providing the moderate sedation:

"Both sets of codes are then further broken down based on the age of the patient and incremental time," says Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley and Associates in Clearwater, Fla. "Additionally, both sets make it clear that the moderate sedation codes are for sedation other than those described by the anesthesia codes. Moderate sedation does not include minimal sedation (anxiolysis), deep sedation, or monitored anesthesia care (MAC)."

"Use 99143-99145 when services are provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status," Center explains.

Plus: Revisions in CPT 2006 mean you also now have the option of reporting moderate sedation if your physician provides the sedation service and a different physician provides the primary service.When a second physician -- a physician other than the one performing the diagnostic or therapeutic services -- provides moderate sedation in a facility setting (e.g., hospital, outpatient hospital/ambulatory surgery center, skilled nursing facility, etc.), you would report 99148-99150 if you are coding for the second physician (who provided the sedation). However, for the circumstance in which the second physician performs these services in the non-facility setting (such as the physician office or a freestanding imaging center), you should not report codes 99148-99150, Center adds.

Good news: CMS gave the green light for Medicare carriers to pay for moderate sedation codes 99143-99145, according to a MLN Matters article (#MM5618) released in August. 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.

The catch: While the guidance explained in the MLN Matters article, which went into effect on Oct. 1, gave carriers the OK that it would be acceptable to process these codes for payment, CMS still doesn't promise payment. The codes are "Status C," meaning they are carrier-priced and do not carry any assigned RVUs, says Mac."Regional Medicare carriers and third-party payers will make their own payment policies for the reimbursement of moderate (conscious) sedation services and should be specifically queried for their billing guidelines and requirements," Mac explains.

There are some procedures the CPT instructs you to never separately report moderate sedation with. If you see a procedure code in the CPT manual with a dot inside a circle (which looks a lot like a target "bull's eye") next to it, you-ll know that you shouldn't report moderate sedation separately with that procedure."According to Appendix G in the CPT manual, the targeted codes with the bull's eye symbol mean that conscious sedation is included in the code as an inherent part of providing the procedure," says Center. "Because these services include moderate sedation, it is not appropriate for the same physician to report both the service and the sedation codes 99143-99145. Payers expect that the physician will provide conscious sedation to the patient as part of one of these services."

Note: The instructions in Appendix G assume that the same physician who is providing the service is providing the moderate sedation. "In the unusual event when a second physician other than the health care professional performing the diagnostic or therapeutic services provides moderate sedation in the facility setting for the procedures listed in Appendix G, the second physician can report 99148-99150," says Center. "However, for the circumstances in which these services are performed by the second physician in the non-facility setting, codes 99148-99150 would not be reported."

What to watch: Targeted codes include many common endoscopic procedures, such as esophagoscopy (43200-43232), upper GI endoscopy (43234-43259), proctosigmoidoscopy (45303-45327), colonoscopy (45355-45392), and others.

Bottom line: You can't bill separately for moderate sedation using 99143, 99144, or 99145 if your surgeon provides both moderate sedation and a targeted service (for instance, 43234, Upper gastrointestinal endoscopy, simple primary examination [e.g., with small diameter flexible endoscope] [separate procedure]).