Oncology & Hematology Coding Alert

When your oncology practice provides moderate sedation for patients undergoing bone marrow or spinal tap procedures, you may find it hard to get paid for codes 99143-99145. But while collecting dollars for the services may still be difficult, recent Medicare guidance may justify separate payment -- and at least one big insurer is following CMS- lead.

"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.

Background: Historically, Medicare carriers only paid for 99148-99150 (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 ...), the moderate sedation codes that cover a situation in which one physician performs a procedure and another physician sedates the patient.

But starting Oct. 1, 2007, Medicare instructed its carriers to cover and pay for the moderate sedation codes that include sedation that a single physician performs in addition to the procedure:

- 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; younger than 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).

"Physicians who both perform and provide moderate sedation for medical/surgical services will be paid for the conscious sedation consistent with CPT guidelines. However, if the physician performing the procedure provides local or minimal sedation for the procedure, then no separate payment is made for the local or minimal sedation service," according to MLN Matters transmittal No. MM5618.

(Find the article online at www.cms.hhs.gov/MLNMattersArticles/downloads/MM5618.pdf.)

Both Medicare and the CPT manual define moderate sedation as follows: "A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. It does not include minimal sedation, deep sedation or monitored anesthesia care."

Watch for: Payers consider moderate sedation an intrinsic part of over 280 procedures, all of which are listed in Appendix G of your CPT manual. A Correct Coding Initiative (CCI) edit has bundled all of these codes into the moderate sedation codes -- so you cannot report 99143-99145 along with any CPT code listed in Appendix G.

Insurer UnitedHealthcare (UHC) announced earlier this year that it would separately reimburse 99143-99145 beginning in the third quarter of 2007. However, along with the Appendix G exceptions, UHC's policy change does not apply to several radiation/oncology procedures. You still cannot report moderate sedation with procedures such as:

- 77280-77295 -- Therapeutic radiology simulation-aided field setting ...

- 77300 -- Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and depth dose, as required during course of treatment, only when prescribed by the treating physician

- 77326-77328 -- Brachytherapy isodose plan ...

- 77336 -- Continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment documentation in support of the radiation oncologist, reported per week of therapy

- 77370 -- Special medical radiation physics consultation

- 77781-77784 -- Remote afterloading high-intensity brachytherapy ....

According to the transmittal, Medicare assigned the 99143-99145 codes a "C" status indicator under the Medicare Physician Fee Schedule, meaning that "CMS has not established relative value units (RVUs) for these services," Medicare states.

The new transmittal gives "no guidance at all as to payment," says Margaret Loftus, a coder with Stanford Hospital and Clinics in Palo Alto, Calif. "The codes are carrier-priced, which means every Medicare carrier is free to value them as they will."

Hope for future pay: As long as these codes are status "C," carriers have discretion on what amount to pay for them. However, this step means that Medicare may add RVUs to all of the moderate sedation codes in 2008 (or at some other time soon).