Neurology & Pain Management Coding Alert

CPT 2006 gives you expanded options for managing young patients

In the new year, you will need to follow suit with CPT 2006 and delete conscious sedation from your coding options. If you use sedation to keep a patient still during an MRI or CT, you-ll need to report your services using a new time-based family of codes.

Get Cozy With the New Codes

Beginning Jan. 1, you will no longer be able to report codes 99141 (Sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation) or 99142 (-oral, rectal, and/or intranasal). In their place, the CPT update introduces a new group of services under the term -moderate sedation,- but don't let the new name confuse you.

Moderate sedation is the same service that you previously reported as conscious sedation. It is a relaxed state of consciousness that is achieved by administering medication intravenously or orally. Individuals are awake, but drowsy, and able to maintain their airways and ability to respond to stimulation or verbal commands. Neurologists will sometimes use sedation to keep patients still, especially children, for certain procedures. 

Turn to these codes to report moderate sedation in 2006:

- 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; under 5 years of age, first 30 minutes intra-service time

- 99144---age 5 years or older, first 30 minutes intra-service time

- +99145---each additional 15 minutes intra-service time (list separately in addition to code for primary service)

- 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; under 5 years of age, first 30 minutes of 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).

Account for Additional Time

While conscious and moderate sedation are essentially the same procedure, how you report this service will require some adjustments for 2006. Instead of coding your surgeon's anesthesia services based on administration method, you will soon choose the proper code based on the patient's age, the providing physician(s), and total -intra-service- time.

CPT 2006 spells out how you should start and stop the clock to properly record for this service, and you need to make sure you keep an eye on these three elements:

1.  Start recording intra-service time when the physician administers the sedation agent.
2.  Document continuous face-to-face attendance.
3.  Stop intra-service time when the providing physician ends personal contact.

Remember: Just like with the old sedation codes, the guidelines for moderate sedation require the services of an -independent trained observer- monitoring the patient's status while under sedation.

When you are serving double duty by providing moderate sedation and performing the primary procedure, you should report one unit of 99143 or 99144 for the first 30 minutes. Choose which of these codes is most appropriate by looking at the patient's age, and reporting 99143 for patients under 5, or 99144 for patients 5 years of age or older.

This grouping by age -makes sense, because a physician may need to administer sedation to a child in order to keep him still, whereas other patients would most likely not need it,- says Katie Cianciolo, RHIA, CCS, CCS-P, a Wisconsin-based coding consultant. Missed opportunity: -They probably should have made a determination to also include individuals with developmental disabilities in this category, because you can't always properly explain a procedure, and sedation may be required even for things like an x-ray,- Cianciolo says.

If your intra-service time extends beyond 30 minutes, you can add 99145 onto the appropriate base code for each additional 15 minutes. These new codes will make it easier -to realize what work is involved- in moderate sedation, says Marvel Hammer, RN, CPC, CHCO, owner of MJH Consulting, a reimbursement consulting firm in Denver. -There are differences in risk for somebody providing sedation services for something that's three minutes versus an hour, because that patient's airway may be in jeopardy longer,- Hammer says.

New option: CPT 2006 also offers a specific code family for when a physician performing any procedure requests moderate sedation services from another doctor. In such cases, the physician who administers and monitors the anesthesia can report 99148 or 99149, once again depending on the age of the patient. You should also report additional time beyond the first 30 minutes using 99150.

Expect Same Old Payment Hassles

Even with new codes and guidelines for moderate sedation, Medicare shocked no one when it assigned zero relative value units (RVUs) to codes 99143-99150 in its recently released 2006 physician fee schedule. While Medicare has never paid for sedation, the failure to assign any RVUs to the new codes could complicate your reimbursement pursuits with private payers.
 
Medicare is now leaving reimbursement determinations up to their individual carriers. -I don't really know if Medicare carriers would entertain to cover these services, but the unfortunate part is that there are no RVUs associated. So now all the individual carriers and commercial payers that base reimbursement on a certain percentage of Medicare's fee schedule will find that all of a sudden no fee is established,- Hammer says.

The jury is still out on how carriers will respond, but many experts forecast an uphill battle. When payers have to assign their own fees, it becomes very easy to just decide not to reimburse, Hammer says.