General Surgery Coding Alert

Be sure to bundle CS to all procedures in Appendix G

CPT 2006 includes a major overhaul of conscious (or moderate) sedation (CS) codes, but the guidelines for these services are still a bit tricky. Read on to unravel the riddle of when your surgeon can report CS separately.

Targets Tell You Not to Report CS

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 CS separately with that procedure, says Michael A. Granovsky, MD, CPC, FACEP, vice president of Medical Reimbursement Systems, an emergency department billing company in Stoneham, Mass.

Instructions in Appendix G of CPT explain that certain codes include conscious sedation -as an inherent part of providing the procedure. These codes are identified in the CPT codebook with [the target] symbol.- The instructions go on to note that if the same physician provides a -targeted- code and the CS, -it is not appropriate - to report both the service and the sedation codes 99143-99145.-

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 CS using 99143, 99144 or 99145 (see -Wake Up and Learn Your New CS Codes- on the facing page for complete definitions of the new CS codes) if your surgeon provides both CS and a targeted service (for instance, 43234, Upper gastrointestinal endoscopy, simple primary examination [e.g., with small diameter flexible endoscope] [separate procedure]).

A Trained Observer Is Necessary

When the primary physician provides CS, you should have an independent, trained observer on hand to help monitor the patient.

Specifically, documentation should provide proof of the observer's presence and note that the observer monitored the patient's cardiorespiratory functions (pulse oximetry, cardiorespiratory monitor and blood pressure) for the duration of the CS. In addition, the physician documentation should record a presedation and post-sedation assessment, Granovsky says.

Watch Place of Service for 99148-99150

You may be able to report 99148-99150 for CS during a targeted procedure, says Kelly Dennis, MBA, CPC, ACS-AP, president of Perfect Office Solutions Inc. in Leesburg, Fla., but the service must meet two requirements:

1. A second physician (not the physician providing the service that supports the CS) must provide the CS.

2. The targeted procedure that prompts the CS and the CS must take place in a facility setting.

Not in the office: You cannot bill report 99148-99150 in the physician's office or other nonfacility setting, even if a second (different) physician provides the CS while the primary physician renders the targeted service that supports the CS, according to newly added CPT language.

Modifier 52 Isn't Necessary

If your surgeon does not provide CS during a targeted procedure, you shouldn't consider the service to be -reduced.- CPT specifically states that you need not append modifier 52 (Reduced services), for example, -when the patient does not require sedation.-

In other words: You will not gain extra reimbursement for providing CS in most cases, but neither will your payment decrease if you don't provide CS.