Orthopedic Coding Alert

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.

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 should read as follows:

The appropriate J code is added for the analgesics or sedatives used.

Similarly, an on-call orthopedist in the emergency department (ED) treats a 7-year-old boy who has fallen from a tree and has a closed displaced fracture of his radius and ulna. The child is in significant pain and is scared of being at the hospital. The orthopedist administers conscious sedation, and an ED nurse monitors the patient while the orthopedist reduces the fracture.

The encounter is coded as follows:

Because the x-rays were conducted and presumably interpreted by the hospital's radiologist, the orthopedist may not bill for them. Likewise, any casting or strapping material that might be billable by a private practice is, in this case, supplied by the hospital and should not be coded by the physician.

Even when the orthopedist presents legitimate reasons for using conscious sedation, reimbursement may still present problems. First, Medicare will not pay for conscious sedation. Although Local Part B carriers have the discretion to pay for this service, few do, and the same is true for state Medicaid programs. This is obviously frustrating to physicians and coders alike because, in some cases, conscious sedation is the only method short of general anesthesia a more costly, risky procedure by which certain treatments can be rendered.

Some private carriers will pay for conscious sedation. Fractures and lacerations are the most common problems for which a physician might opt for conscious sedation, but CPT has no specific rule limiting which codes might apply for conscious sedation. For carriers that will consider claims for conscious sedation, documentation must include the following:

Fulton adds that the practice will only bill separately for conscious sedation when a registered nurse is in the room to monitor the patient. "We have not had any problems with reimbursement," Fulton says, "however, we've not utilized the code very often."

Although some coding sources indicate that when billing for conscious sedation, the physician can also bill for catheter placement (36000*, Introduction of needle or intracatheter, vein), you should keep in mind the American Academy of Orthopaedic Surgeons (AAOS) guide, which bundles "insertion, placement, and removal of surgical drain(s), reinfusion device(s), irrigation tube(s), catheter(s), or suction device(s)" with virtually every orthopedic procedure. Carriers who follow AAOS guidelines likely will not pay for catheter placement given this rule.

You should also note that certain codes in the musculoskeletal system (and elsewhere in CPT) specify "with anesthesia" or "without anesthesia" (e.g., 24600, Treatment of closed elbow dislocation; without anesthesia, and 24605, requiring anesthesia). Because "requiring anesthesia" means general anesthesia and those codes reimburse at a higher level, using conscious sedation does not qualify the service for a "requiring anesthesia" code. Therefore, you should bill for the service without anesthesia and submit the conscious sedation code as well. Ultimately, a trial-and-error approach will prove which carriers will pay for conscious sedation when all criteria are met, and which will not, regardless of circumstances.