Part B Insider (Multispecialty) Coding Alert

Published on Tue Jul 24, 2007 PDF

Tip: Make sure your doctor documents the level of sedation

Good news: More Medicare carriers may start paying for moderate sedation codes 99143-99145 soon.

Right now, many carriers will only pay for 99148-99150, which cover a situation where one physician performs a procedure and another physician sedates the patient. (See The Insider, Vol. 8, No. 23.) They won't cover 99143-99145, which cover sedation which a single physician performs in addition to the procedure.

But a new transmittal suggests that the Centers for Medicare & Medicaid Services may be encouraging carriers to pay for both types of sedation. -The new policy is as follows: If the physician performing the procedure also provides moderate sedation for the procedure then payment may be made for conscious sedation consistent with CPT guidelines,- says Transmittal 1316 (Change Request 5618.)

The new language is a -positive sign,- and may show that Medicare is responding to providers- letters in support of moderate sedation, says David McKenzie, CAE reimbursement director with the American College of Emergency Medicine.

Medicare appears to be saying that the carriers should pay for 99143-99145 when the same physician performs a procedure and sedation, with a trained observer present, says Margaret Loftus, a coder with Stanford Hospital and Clinics in Palo Alto, CA. Watch out: You can't bill 99143-99150 with the codes listed in Appendix G of the CPT book, because those codes include conscious sedation.

-Carriers now have the OK that it would be acceptable from Medicare to process these codes for payment,- says Marvel Hammer with MJH Consulting in Denver, CO. But she cautions that Medicare uses the word -may,- not -must- or -should.-

Also, the new transmittal gives -no guidance at all as to payment,- Loftus notes. -The codes are carrier priced which means every Medicare carrier is free to value them as they will.- And as long as these codes are -Status C,- the carriers have discretion on whether to pay for them.

CMS hasn't yet released the MLN Matters article to go with this transmittal. That article may shed more light on how, or whether, Medicare will pay for these codes. The -best-case scenario- is that Medicare may actually add RVUs to all of the moderate sedation codes in 2008, Hammer adds.

Important: Make sure your documentation specifies the -level- of sedation, Hammer stresses. The transmittal makes clear that you shouldn't bill 99143-99145 just for local anesthestic or minimal sedation.