Neurosurgery Coding Alert

Question: Especially when dealing with young children, our surgeon will administer conscious sedation during difficult procedures (such as spinal taps). How should we report this?

Texas Subscriber

Answer: 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 surgeon also performs the primary procedure (such as percutaneous aspiration of nucleus pulposis). Conscious sedation includes performance and documentation of pre- and postsedation evaluations, administration of sedation and/or analgesic agent(s), and monitoring of cardiorespiratory function.
 
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 surgeon provides conscious sedation in support of another physician, the surgeon 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 Eric Sandham, CHC, CPC, compliance manager for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno.