Medicare Compliance & Reimbursement

Medicare is keeping watch over providers' code usage.

Medicare never paid for conscious sedation in the past, but some observers are hopeful things will be different for moderate sedation.

Current Procedural Terminology 2006 introduced six new codes for "moderate sedation" (99143-99150) and deleted two old "conscious sedation" codes (99141-99142). For now, the new codes have a status of "C," meaning "carrier-priced."

"Unfortunately, carrier-priced often means zero" for reimbursement, says David McKenzie, director of reimbursement with the American College of Emergency Physicians. But there is something providers can do.

Now's the time for providers to encourage their local Part B carriers to reimburse these codes, say experts. The carriers can come out with Local Coverage Determinations for these codes, notes Steven Verno, director of reimbursement for Emergency Medicine Specialists in Hollywood, FL. United Healthcare has promised on its Web site to introduce a policy on these codes in its March 2006 provider newsletter.

Already, some Medicaid programs will pay for moderate sedation for children. For example, if a child comes in with a high fever and the doctor suspects meningitis, the doctor may need to give the patient a spinal tap under moderate sedation, says Verno.

The Relative Value Update Committee suggested adequate national RVU values for the moderate sedation codes, the American Association of Family Physicians noted in its comments on the 2006 physician fee schedule.

But the Centers for Medicare & Medicaid Services said it wanted more data first. "We are uncertain whether the RUC-assigned values are appropriate and have carrier-priced these codes in order to gather information for utilization and proper pricing," CMS said in the Nov. 21, 2005 Federal Register (page 70282).

Simply put, it's in physicians' interest to bill these codes now--even if they may not receive payment. That way, CMS will gain more information on utilization and may consider adding national RVUs next year.

For now, the best thing providers can do is check with their carriers on how to report these codes, says McKenzie.