Orthopedic Coding Alert

Orthopedists and their coders often ask about the legitimacy of billing for conscious sedation when performed at the same time as an orthopedic procedure. Although the global charge for most orthopedic surgeries includes the administration of anesthesia or sedatives, conscious sedation occasionally can be legitimately billed separately.

Conscious sedation is mild or moderate sedation used to alter mood and behavior but not completely anesthetize the patient. Conscious sedation is the intermediary step between local anesthesia and full sedation patients are still conscious but in an altered state that makes them more relaxed, and the anesthesia masks most or all of the discomfort associated with a procedure.

CPT has two codes for conscious sedation: 99141 Sedation with or without analgesia (conscious sedation); intravenous, intramuscular or inhalation 99142 ... oral, rectal and/or intranasal. Unlike other anesthesia codes, 99141 and 99142 can be reported by physicians other than anesthesiologists or nurse anesthetists. In the orthopedic setting, in-office procedures like fracture reductions are often treated with local anesthesia, an injection given prior to the reduction that numbs the involved area. For most patients, this provides sufficient anesthesia to allow the reduction to be performed without great discomfort. According to the American Academy of Orthopaedic Surgeons' Complete Global Service Data Guide for Orthopedic Surgery, "local infiltration of medication, anesthetic or contrast agent" is bundled with every orthopedic procedure as a "generic" bundle. When Is Conscious Sedation Used? In certain circumstances, conscious sedation may be used instead of local anesthesia, particularly with very young or very old patients or the mentally impaired when nervousness, mood or inability to cooperate might impair the physician's ability to perform a certain service, like the reduction of a fracture or dislocation. Beth Fulton, CPC, coding specialist at Orthopaedic Specialists of the Carolinas in Winston-Salem, N.C., says her practice occasionally uses conscious sedation to manipulate fractures.

For example, an 80-year-old female patient with advanced Alzheimer's disease is brought by her daughter to the orthopedist with a swollen wrist after a fall. The physician suspects a fracture, but because of the patient's dementia and agitated state, he has difficulty conducting an examination, and x-rays seem out of the question. The orthopedist confers with the patient's daughter and determines that conscious sedation is the best route for completing the examination, x-rays and fracture reduction, if necessary. He sedates the patient, who is then x-rayed in-house. X-rays reveal a Colles' fracture (813.xx) of the wrist, and the physician sets and casts the wrist before the patient is brought out of sedation. The practice nurse is present during the entire procedure to monitor the patient's vitals while she is under sedation.

Given the circumstances of this example, conscious sedation is legitimately billable. The claim form [...]