Orthopedic Coding Alert

Question: Especially when dealing with young children, our surgeon will administer conscious sedation during difficult procedures (such as fracture manipulation). How should we report this?
      
Texas Subscriber Answer: You should use 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 orthopedic surgeon also performs the primary procedure. 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" must be present to assist the physician in monitoring the patient's level of consciousness and physiological status. The observer need not be another physician.
 
A statement in CPT specifies, "If the sedation with or without analgesia is administered in support of a procedure provided by another physician, see the anesthesia section." This is directed specifically toward anesthesiologists, not surgeons who perform both the procedure and the sedation.