Internal Medicine Coding Alert

Question: What are Medicare's pay policies for the new moderate (conscious) sedation codes? Can we receive payment for any of the sedation codes?

Alabama Subscriber

Answer: There has been some movement on the moderate sedation pay front, but getting paid for the services will still be difficult.

Currently: Medicare carriers will only pay for 99148-99150 (Moderate sedation services [other than those services described by codes 00100-01999] provided by a physician other than the healthcare professional performing the diagnostic or therapeutic service that the sedation supports ...), codes that cover a situation in which one physician performs a procedure and another physician sedates the patient.

But starting Oct. 1, Medicare will allow payers to cover 99143-99145 (Moderate sedation services [other than those services described by codes 00100-01999] 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 ...), codes that cover sedation that a single physician performs in addition to the procedure.

"Physicians who both perform and provide moderate sedation for medical/surgical services will be paid for the conscious sedation consistent with CPT guidelines. However, if the physician performing the procedure provides local or minimal sedation for the procedure, then no separate payment is made for the local or minimal sedation service," according to MLN Matters transmittal MM5618.

According to the transmittal, Medicare will allow its payers to process these codes for payment in October. But just because carriers can pay for these codes does not mean they will.

The moderate sedation codes are still carrier-priced which means every Medicare carrier is free to value them as it will. According to the transmittal, Medicare assigned the 99143-99145 codes a "C" status indicator under the Medicare physician fee schedule, meaning that "CMS has not established relative value units (RVUs) for these services," Medicare says.

Hope for future pay: As long as these codes are status "C," the carriers have discretion on whether to pay for them. However, this step means that Medicare may add RVUs to all of the moderate sedation codes in 2008 (or at some other time soon).