Ob-Gyn Coding Alert

Discover the 1 exception to the -targeted- code rule
 
When your physician performs moderate (or conscious) sedation on a patient, you may be tempted to neglect reporting the sedation to the insurer. After all, many carriers still don't reimburse for the service, which CPT anointed with a new code set in 2006.

Leaving these codes off the claim could be a mistake, however, because some insurers have started paying for moderate sedation, says Robert LaFleur, MD, of Medical Management Specialists in Grand Rapids, Mich.

-Reimbursement for moderate sedation has been spotty,- he says. But LaFleur goes on to say that some payers have started paying for certain types of moderate sedation.

Additionally, Medicare designated these codes as -carrier-priced- to gather information for utilization and proper pricing.

-Many Medicare carriers are beginning to recognize moderate sedation,- says Michael Granovsky, MD, CPC, president of MRSI, a coding and billing company in Woburn, Mass. So while you may not get paid every time you report moderate sedation, including it on the claim when you-re allowed to is a good idea.

Benefit: The more times an insurer sees moderate sedation codes on claims, the more likely it will be to consider paying for the service in future policy decisions.

If you are confused about coding for these services, check out this primer on the ins and outs of moderate sedation coding.

Use 99144-99145 for Procedure, Sedation

You should see two sets of moderate sedation codes, which are separated based on the number of physicians involved. You-ll choose from one of these codes when the same physician performs the sedation and the procedure (or service), says Cheryl Tereba, a manager of revenue recovery for UMass Memorial Healthcare in Worcester, Mass.:

- 99144 -- 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; 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).

Remember: When using moderate sedation codes, you must be sure the medical record contains a thorough explanation of the medical necessity for performing this service.

Don't Code Separately for IV Establishment
 
 When you provide moderate sedation, you should not report the following services, because they-re included:

 - Assessing the patient (not included in intraservice time)

 - Establishing IV access and fluids to maintain patency, when performed

 - Administering agent(s)

 - Maintaining sedation

 - Monitoring oxygen saturation, heart rate and blood pressure

 - Recovery (not included in intraservice time).
Remember: Intraservice time starts with the administration of the sedation agent(s), requires continuous face-to-face attendance and ends at the conclusion of personal contact by the physician providing the sedation.

Learn by This Example

To illustrate how you would properly use these codes, consider this example:

Scenario: A 30-year-old established patient presents with a new problem -- severe vaginal bleeding that requires an endometrial biopsy. The patient is extremely apprehensive, and the physician notes some cervical stenosis that will require cervical dilation before performing the procedure. The patient lives 100 miles away and just -wants to get it over with.- After conducting the initial history and exam with the finding of stenosis, the physician decides that the patient won't tolerate the biopsy well without sedation.

The physician supervises the nurse while she performs administration and induction of an intravenous sedating agent without an analgesic. This makes the patient sleepy but responsive to commands. The physician then inserts cervical dilators and then proceeds with the endometrial sampling. The entire procedure takes 20 minutes.

Solution: In this scenario, you should code for moderate sedation. On the claim,

 - report 58120 (Dilation and curettage, diagnostic and/or therapeutic [nonobstetrical]) for the endometrial sampling with cervical dilation. Note: NCCI permanently
bundles the code for cervical dilation (57800, Dilation of cervical canal, instrumental [separate procedure]) into the code for an endometrial sampling (58100, Endo-metrial sampling [biopsy] with or without endocervical sampling [biopsy], without cervical dilation, any method [separate procedure]).

 - report the appropriate E/M code (99211-99215) based on the encounter specifics.

 - attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code to show that the drainage and E/M were separate services.

 - report 99144 for the sedation linked to 622.4 (Stricture and stenosis of cervix) with a possible secondary diagnosis of anxiety (300.02, Generalized anxiety disorder) to fully explain the medical indication for this sedation.

 - link 626.6 (Metrorrhagia) to 58120, the E/M code and 99144 to prove medical necessity for these procedures.

Leave Sedation Codes Off -Targeted- Procedures

When you-re considering a conscious sedation code, you should observe one important restriction: If the code for the procedure has a -target- symbol (8) next to it in the CPT manual, you cannot report conscious sedation along with the code unless two providers are involved, Granovsky says. If you report a conscious sedation code from the single-physician set of 99143-99145 along with a -targeted- code, you-ll receive a denial.

Keep in mind: You-ll find a list of targeted codes in CPT's Appendix G under the heading -Summary of CPT Codes That Include Moderate [Conscious] Sedation.- Specifically, you would not report conscious sedation if the physician is performing a percutaneous drainage of a pelvic abscess (58823, Drainage of pelvic abscess, transvaginal or transrectal approach, percutaneous [e.g., ovarian, pericolic]).

Exception: There is one scenario in which insurers may allow you to report a conscious sedation code in addition to a targeted code. If the encounter occurs in the emergency department -- and one physician performs the procedure and a second physician oversees the sedation -- you can report 99148-99150 along with an Appendix G-listed procedure code, Granovsky says.

Encounters of this sort, however, are not that common, LaFleur says. -CPT suggests that needing a second physician for any of the targeted procedures is unusual,- he says.