Neurology & Pain Management Coding Alert

Question: Especially when dealing with young children, our neurologist will administer conscious sedation during difficult procedures such as spinal taps. How should we report this? May we use anesthesia codes such as 01922?

Discussion List Participant

Answer: No, you should not use 01922 (Anesthesia for non-invasive imaging or radiation therapy) or other general anesthesia codes to report conscious sedation.
 
You should report 99141 (Sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation) or 99142 (... oral, rectal and/or intranasal), as appropriate, to report conscious sedation when the neurologist also performs the primary procedure (such as a CT scan). Conscious sedation includes performance and documentation of pre- and postsedation evaluations, administration of sedation and/or analgesic agent(s), and monitoring of cardiorespiratory function (i.e., pulse oximetry, cardio-respiratory monitor, and blood pressure).
 
The same physician who performs the primary procedure normally provides conscious sedation, although CPT does specify that an "independent trained observer" be present to assist the physician in monitoring the patient's level of consciousness and physiological status. The observer need not be another physician.
 
The statement in CPT specifying "If the sedation with or without analgesia is administered in support of a procedure provided by another physician, see the anesthesia section" is directed specifically toward anesthesiologists.
 
If the neurologist provides conscious sedation in support of another physician, the neurologist must consider local licensing rules and regulations and scope-of-practice laws before reporting an anesthesia code.
 
- Clinical and coding expertise for You Be the Coder and Reader Questions provided by Neil Busis, MD, chief of the division of neurology and director of the neurodiagnostic laboratory at the University of Pittsburgh Medical Center at Shadyside, and clinical associate professor in the department of neurology, University of Pittsburgh School of Medicine; and Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J.