Pediatric Coding Alert

The conscious sedation codes (99141 for intravenous, intramuscular, or inhalation and 99142 for oral, rectal and/or intranasal) are two years old, but health plans are still resisting recognizing them. For some reason, they dont understand why something like an MRI or a facial laceration repair would not require medication (except perhaps novocaine) on an adult, but would require sedation on a child. Let them take their three-year-old to the emergency room for an endoscopy, says Debra Beauregard, executive director of business operations for the CHOC Pediatric Subspecialty Facility, a 58-provider group in Orange, Calif.

But Beauregards annoyance over the problems getting paid for these codes is finally abating. She has come up with a way to get them reimbursed most of the time. When we started using these codes, they were always denied, she says. So we changed our charge tickets. Now we actually have a space where we put down what drug were using and the start and stop time for the sedation. Increasing the documentation in this way has worked, saving Beauregard from endless appeals. Beauregards group uses conscious sedation for lumbar punctures and endoscopies, among other procedures.

Note: Pediatricians should remember that these codes require a second person to monitor the patient. You cant just give chloral hydrate and do a lumbar puncture without a second person to do monitoring if you want to use these codes. And you should document the monitoring, as well.

Were using 99141-99142, but still fighting to get them paid, says Jean Pletl, ART, CCS-P, compliance and documentation specialist with Childrens Specialty Group, a 70-provider group of pediatric subspecialists in Norfolk, Va. One physician does Botox injections, and she lightly sedates the children because these shots are painful, says Pletl. But its not only for discomfort that children require conscious sedation; sometimes, a young child just needs help staying still. Even for an MRI, these kids need to be sedated, says Pletl.

The only way Pletl has managed to convince payers to reimburse for conscious sedation is to show that there is a benefit to the patient. We went to the highest level at CHAMPUS, she says (there are many patients covered by the military). They were denying these codes because they said they werent medically necessary. Basically, we said, `You tell the parents that it wasnt medically necessary. It turned out that CHAMPUS didnt actually have a policy refusing to pay for the codes; rather, they just didnt pay them. Because there was no policy contraindicating payment, Pletls appeals got somewhere. Now, they say theyll pay for conscious sedation, she says.

Who Administers the Sedation?

The conscious sedation code is not a simple code to use. If you remember that the pediatrician who does the procedure must also administer the sedation, you will find it easier to charge this code. Who administers the sedation? is a question that pediatricians often ask. The answer is: The physician who is performing the procedure administers the sedation. As mentioned above, a second personusually a nursemust be present to monitor vital signs and the level of sedation. The point that CPT makes on this code is that there is only one physician present (i.e., no anesthesiologist).

For example, a radiologist is performing an MRI, and the pediatrician is asked to order chloral hydrate or a sedative for the child. The pediatrician cant bill for prescribing. The radiologist will administer and charge for the conscious sedation, as well as the MRI. But if a pediatrician is performing a lumbar puncture, and administering the conscious sedation, the pediatrician would bill both codesproviding there is a second person there to monitor the child.