Pediatric Coding Alert

Conscious sedation codes 99141 (intravenous, intramuscular or inhalation) and 99142 (oral, rectal and/or intranasal) are intended to report a service administered by the same physician who is performing the primary procedure. Both codes are modifier -51 (multiple procedures) exempt, meaning the physician providing the sedation can bill it with other procedures and be paid the full fee. When a second physician provides the conscious sedation, however, CPT requires the use of the anesthesia codes (00100-01999). Those pediatricians who perform conscious sedation in support of another physician and bill 99141 or 99142 are forfeiting deserved reimbursement.

Standard of Care Requires Pediatricians Presence

Often, for instance, a radiologist requests that a pediatrician administer conscious sedation for a child undergoing an MRI. Although, technically, the radiologist could perform the sedation, many radiologists as well as hospital administrators concerned about liability believe a pediatrician is better qualified to administer and monitor conscious sedation for a child. Radiologists may not feel comfortable handling an airway emergency especially for a child.

The standard of care is to have someone experienced with a pediatric airway emergency present throughout the conscious sedation procedure, explains Mike Cinoman, MD, director of the pediatric intensive care unit and pediatric inpatient services at WakeMed in Raleigh, N.C. This may be an anesthesiologist, a pediatric intensivist, a pediatric emergency medicine physician or an experienced pediatrician. Nevertheless, the conscious sedation codes clearly allow for a nonphysician (specifically, an independent trained observer) to monitor the patient. The only clear-cut use of the conscious sedation codes for a pediatrician is if the pediatrician administering the sedation is also performing the procedure requiring the sedation, says Joel Bradley, MD, FAAP, editor of the current edition of Coding for Pediatrics and a member of the American Academy of Pediatrics coding and reimbursement committee.

Using the Anesthesia Codes

If a pediatrician provides conscious sedation in support of another physician, he or she can bill an anesthesia code, says Richard A. Molteni, MD, FAAP, CPT editorial panel member. The anesthesia codes can be used by anyone. They are not limited to anesthesiologists, he explains.

The anesthesia codes are arranged according to anatomy. For anesthesia administered during a procedure to the head, for instance, a code should be selected from the 00100-00222 series; for the neck, 00300-00352, etc. Therefore, for conscious sedation delivered while an orthopedic surgeon performs a closed reduction on an ankle fracture, bill 01462 (anesthesia for all closed procedures on lower leg, ankle, and foot).

Subsections within the anesthesia codes also include radiological procedures, burn excisions or debridements, and other procedures. The correct anesthesia code for an MRI, for example, is CPT 01922 (anesthesia for non-invasive imaging or radiation therapy).

Note: When using anesthesia codes on a child under 1 year of age, append +99100 (anesthesia for patient of extreme age, under 1 year and over 70 [list separately in addition to code for primary anesthesia procedure]). This code may not be used with the conscious sedation codes.

Appeal Unfounded Denials

When the conscious sedation codes were introduced, many physicians made the mistake of thinking they could call in a second physician (often, an anesthesiologist) to bill the service, says Barbara Johnson, CPC, coder with the Loma Linda University Anesthesiology Medicine Group in Loma Linda, Calif. However, CPT does not allow this. Theres a fine line between conscious sedation and anesthesia, Johnson says, and its drawn in the monitoring not the delivery of the procedure. A physician delivers both anesthesia and conscious sedation. But while a physician monitors anesthesia, a nurse or other trained observer monitors conscious sedation.

Although the AMA agrees with CPT that pediatricians should use the anesthesia codes when providing conscious sedation in support of another physician, many insurers will only pay an anesthesiologist for these codes.

Do not avoid billing the anesthesia codes which pay well because of fear that the insurance company wont pay. File and, if necessary, appeal. The payer expects the pediatric office to draw their attention to incorrect denials based on their computer edits, says Thomas A. Kent, CMM, CPC, president of Kent Medical Management, a coding consultancy based in Dunkirk, Md. Although the initial claim might be denied based on specialty issues, it should be paid without debate upon your written appeal with the medical record in support, Kent says. If an office is not regularly appealing denials, they may be surprised how many will be paid on just one appeal.

Additionally, a letter to the payer from the physician performing the primary procedure saying he or she requested that the pediatrician administer the conscious sedation may help combat denials.

Children May Need Sedation When Adults Dont

Some payers dont recognize that a procedure performed on an adult without sedation might require medication in a child when the pediatrician must repair a facial laceration (12011), for example or regard conscious sedation as bundled into other procedures. An adult can be told not to move, but, You cant tell a kid that and expect them to sit still, says Harold Koller, MD, FAAP, FACS, chair of the AAP Section on Ophthalmology. He adds that it would be dangerous to perform many procedures on children without some kind of sedation. And although some endoscopies do include sedation, many other procedures, including MRI and flexible sigmoidoscopy, do not. If insurers are rejecting your conscious sedation claims, you may have to contact them and explain that the patient is a child.

Pediatric subspecialists could code conscious sedation more frequently than their primary care counterparts. For example, a pediatric gastroenterologist uses conscious sedation when performing a sigmoidoscopy (45330); a pediatric ophthalmologist, when performing tear duct probing (68810*) in the office; a pediatric urologist, when performing a circumcision (54152 or 54161) on an older child; a pediatric hematologist, when performing a bone-marrow aspiration (85095); and a pediatric neurologist, when performing a botox injection (64614). These procedures may require no sedation when performed on an adult, but almost always require sedation on a child.

Note: Because of the difficulty of dealing with young patients, pediatric subspecialists often choose general anesthesia and the operating room over conscious sedation and an office procedure when performing a minor surgery.