Internal Medicine Coding Alert

Published on Wed Mar 07, 2007 PDF

Coders report that some insurers are now reimbursing sedation
 
When your physician performs moderate (or conscious) sedation on a patient, you may be tempted to neglect reporting the sedation to the insurer. After all, many carriers are still not reimbursing for the service, which CPT anointed with a new code set in 2006.

Leaving these codes off the claim could be a mistake, however, because some insurers have started paying for moderate sedation, says Robert LaFleur, MD, of Medical Management Specialists in Grand Rapids, Mich.

"Reimbursement for moderate sedation has been spotty," he concedes. But LaFleur goes on to say that some payers have started paying for certain types of moderate sedation.

Additionally, Medicare designated these codes as "carrier-priced" in order to gather information for utilization and proper pricing.

"Many Medicare carriers are beginning to recognize moderate sedation," says Michael Granovsky, MD, CPC, president of MRSI, a coding and billing company in Woburn, Mass. So while you may not get paid every time you report moderate sedation, it is a good idea to include it on the claim when you're allowed to.

Benefit: The more times an insurer sees moderate sedation codes on claims, the more likely it will be to consider paying for the service in future policy decisions.

If you are confused about coding for these services, check out this primer on the ins and outs of moderate sedation coding.
 
Use 99143-99145 When Physician Performs Procedure, Sedation
 
There are two sets of moderate sedation codes, which are separated based on the number of physicians involved.  You'll choose from one of these codes when the same physician performs the sedation and the procedure (or service), says Cheryl Tereba, a manager of revenue recovery for UMass Memorial Healthcare in Worcester:

• 99143 (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; younger than 5 years of age, first 30 minutes intra-service time) if the patient is under 5 years old.

• 99144 (... age 5 years or older, first 30 minutes intra-service time) if the patient is 5 years or older.

• +99145 (... each additional 15 minutes intra-service time [list separately in addition to code for primary service]) for each additional 15 minutes of sedation beyond the first half-hour.
 
Remember: When using moderate sedation codes, you must be sure the medical record contains a thorough explanation of the medical necessity for performing this service.

Don't Code Separately for IV Establishment

When you provide moderate sedation, the following services are included and not reported separately:

• Assessment of the patient (not included in intraservice time)

• Establishment of IV access and fluids to maintain patency, when performed

• Administration of agent(s)

• Maintenance of sedation

• Monitoring of oxygen saturation, heart rate and blood pressure

• Recovery (not included in intraservice time).

Remember: Intraservice time starts with the administration of the sedation agent(s), requires continuous face-to-face attendance and ends at the conclusion of personal contact by the physician providing the sedation.

To illustrate proper use of these codes, consider this example from LaFleur:

A 30-year old established patient presents with a new problem: a pilonidal abscess that requires drainage. The area is tender and the patient is apprehensive. After conducting the initial history and exam, the physician decides that the patient won't tolerate treatment well without sedation.

The physician supervises the nurse while she performs administration and induction of an intravenous sedating agent without an analgesic. This makes the patient sleepy but responsive to commands. The physician then incises, drains and packs the abscess. The entire procedure takes 20 minutes.

In this scenario, you should code for moderate sedation. On the claim,

•  report 10080 (Incision and drainage of pilonidal cyst; simple) for the abscess drainage.

•  report the appropriate E/M code (99211-99215) based on the encounter specifics. 

• attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code to show that the drainage and E/M were separate services.

•  report 99144 for the sedation.

•  link 685.0 (Pilonidal cyst; with abscess) to 10080, the E/M code and 99144 to prove medical necessity for these procedures.
 
2-Physician Encounters Call for Different Set of Sedation Codes
 
When a physician administers conscious sedation to a patient, he might ask another physician to provide moderate sedation services while he provides the service (or performs the procedure). This scenario is rare in an internal medicine office. But if this occurs, Tereba says, you should choose from the following codes:

• 99148 -- 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; younger than 5 years of age, first 30 minutes intra-service time

• 99149 -- ... age 5 years or older, first 30 minutes intra-service time

•  +99150 -- ... each additional 15 minutes intra-service time (list separately in addition to code for primary service).

Remember: As with all claims containing moderate sedation codes, check the medical record for a thorough explanation of the medical necessity for performing this sedation service.
 
Leave Sedation Codes Off 'Targeted' Procedures

Coders who are considering a conscious sedation code should observe one important restriction: If the code for the procedure has a TARGET sign ( Black dot with a circle around it ) next to it in the CPT book, you cannot report conscious sedation along with the code unless two providers are involved, Granovsky says. If you report a conscious sedation code from the single- physician set of 99143-99145 along with a "targeted" code, you'll receive a denial. (There is a list of targeted codes in Appendix G of CPT 2007, under the heading "Summary of CPT Codes That Include Moderate [Conscious] Sedation.")

Exception: There is one scenario in which insurers may allow you to report a conscious sedation code in addition to a targeted code. If the encounter occurs in the ED -- and one physician performs the procedure and a second physician oversees the sedation -- you can report 99148-99150 along with an Appendix G-listed procedure code, Granovsky says.

However, encounters of this sort are not that common, LaFleur says. "CPT suggests that needing a second physician for any of the targeted procedures is unusual," he says.