Medicare Compliance & Reimbursement

Look for systemic conditions that support moderate sedation.

So your Medicare carrier (or private payor) has decided to pay for moderate sedation codes 99143-99150 after all. Now, how do you document and code the procedures to make sure you get the correct payment? Our experts offer a few tips:

· Look for MAC coverage policies. Often, the diagnosis codes that carriers list for Monitored Anesthesia Care (MAC) will also work for moderate sedation, notes Marvel Hammer, president of MJH Consulting in Denver, CO.

The patient's condition and co-morbidities should be your main support for medical necessity, Hammer adds. Look for heart or pulmonary conditions, morbid obesity and psychological conditions.

You can also win moderate sedation coverage by pointing to systemic diseases such as Parkinson's, mental retardation or claustrophobia, points out Barbara Johnson, owner of Real Code in Moreno Valley, CA. These conditions might mean the patient needs some sedation to lie still. Also, most patients wouldn't want to undergo a lumbar puncture without either sedation or general anesthesia, she adds.

· Watch out for CCI edits: The Correct Coding Initiative (CCI) bundles moderate sedation codes with a number of evaluation & management, injection, angioplasty and radiology codes.

The bad news is that you can't use a modifier to override most of the edits bundling 99143-99145 into various other codes, notes Hammer. There is no scenario that would allow you to report these moderate sedation services separately.

And the same goes for edits bundling E/M codes into moderate sedation codes. This makes sense, because the section guidelines for moderate sedation indicate that "assessment of the patient is included in the moderate sedation services and should not be separately reported," Hammer says.

· Don't assume that Medicare will never cover 99143-99145, which are for a single physician performing both moderate sedation and a procedure at the same time. True, some Medicare carriers, including CIGNA, United Healthcare and Highmark, have said they will only pay for 99148-99150, which is for two separate physicians performing sedation and surgery. And the CCI's Edit Manual mentions in its first chapter that Medicare won't pay for anesthesia performed by the physician who also performs the surgery. But the manual adds that there's one exception: Medicare may pay for moderate sedation services (99143-99145) when performed by the surgeon, says Hammer.

So although the CCI manual doesn't say Medicare "must" pay for moderate sedation, it does say Medicare "may" pay for it, Hammer explains.

· Anesthesiologists generally won't bill for conscious sedation services, notes Scott Groudine, professor of anesthesiology at Albany Medical Center in Albany, NY. Instead, you'll likely code an anesthesiologist's services using an anesthesia code, usually MAC. But if more carriers start paying for 99143-99145, some physicians might decide to perform moderate sedation themselves, cutting out the anesthesiologist.

· Pay attention to your contract with private payors. It may state whether the health plan will ever pay for moderate sedation services ...quot; and what your appeal rights are, notes Steve Verno, director of reimbursement at Emergency Medicine Specialists in Hollywood, FL.