Pediatric Coding Alert

Although adult patients dont have to be sedated for x-rays, pediatric patients sometimes do. Young children almost always have to be sedated for MRIs and CAT scans. And, most pediatric patients (and adults as well) need to be sedated for endoscopies. So, pediatricians were delighted when the new codes for conscious sedation99141 and 99142made their appearance in the 1998 CPT. However, sometimes its not immediately obvious how new codes will work in combination with other codes.

We tried using the conscious sedation codes as soon as they came out, says Sharon Villamil, billing manager for the Department of Pediatrics at the Childrens Hospital at Albany Medical Center, which has seven primary care pediatricians and 23 subspecialists. We received no payment at all. Was it because the insurance companies hadnt loaded the new codes yet? Possibly. But the solution Villamil found didnt end up working either. Heres what happened.

On a regular basis our critical care physicians perform conscious sedations on pediatric patients who are seen on an outpatient basis for procedures such as MRIs and endoscopies, says Villamil. Critical care physicians are involved by the request of pediatricians in the community, as well as by the request of the specialists performing the procedures, the billing manager notes. They request the intensivists because the treatment involves sedation of a child, which is sometimes more risky, says Villamil.

So, the pediatric specialists did the procedures, with intensivists administering the sedation and monitoring vital signs. At first, Villamil used the first conscious sedation code: 99141. This is for intravenous, intramuscular, or inhalation sedation, because intravenous administration is what they use.

Now, things start to get a little complicated.

Consultation Codes

Our physicians, in addition to performing the conscious sedation, also examine the patient prior to the procedure and bill for a consultation, says Villamil.
This can get you into trouble, advises Liz Munn, practice plan manager at Childrens Hospital, Medical University of South Carolina, in Charleston. The conscious sedation codes call for an exam pre and post. I wouldnt do it, she states, referring to billing the consultation codes.

Indeed, CPT makes it clear that conscious sedation does include the exams. Sedation with or without analgesia (conscious sedation) is used to achieve a medically controlled state of depressed consciousness while maintaining the patients airway, protective reflexes, and ability to respond to stimulation or verbal commands, CPT states. Conscious sedation includes performance and documentation of pre-and post-sedation evaluations of the patient, administration of the sedation and//or analgesic agent(s), and monitoring of cardiorespiratory function (i.e., pulse oximetry, cardiorespiratory monitor, and blood pressure). The use of these codes requires the presence of an independent trained observer to assist the physician in monitoring the patients level of consciousness and physiological status.

Munn concludes that she would be very wary of using a consultation code in combination with conscious sedation.
Janet McDiarmid, CMM, CPC, MPC, national president of the American Academy of Professional Coders Advisory Board, concurs. I would have to agree with the insurance companies, says McDiarmid. They dont need both physicians there. Unless the procedure requires an anesthesiologist, says McDiarmid, the only physician who should be required is the one doing the endoscopy, for example.

If the procedure is performed in the endoscopy suite of the hospital, the fee of the nurse, who is monitoring the patient, will be a part of the facility fee, notes McDiarmid. There is no reason to have two physicians, she emphasizes.

Critical Care Pediatricians

But, it is a good idea for the specialist performing the procedure to be a critical care physician, says Charles A. Scott, MD, FAAP, a regional CPT coding resource physician for the American Academy of Pediatrics. I can understand the concern about safety, says Scott. Critical care physicians are capable of handling problems, he notes. Who better to have there if a kid codes?
Villamil notes that the community pediatricians who are referring patients to the hospital for these procedures are requesting that a critical care doctor be there to administer the sedation.

If the concern is liability, thats an issue for the doctors and the hospital to work out, says McDiarmid, who is office manager for a surgeon. When endoscopies are done, including on children, says McDiarmid, there is always an additional provider there solely to monitor vital signs. But, this person is never a physiciannot even when the patient is a child.

90780 Instead?

Coding for conscious sedation didnt work for us, reports Villamil. So, she switched to 90780, which is IV infusion for therapy/diagnosis, administered by physician or under direct supervision of physician. 90780 is for the first hour; 90781 is for each subsequent hour, up to eight hours.

90780 specifically requires the presence of a physician during the infusion. Villamil says that for a while, insurance companies paid. But now I get a lot of denials, she reports.

The problem appears to be that a second physician is involved in a procedure which should only take one. If its an MRI, the doctor doing the test can administer the sedation, says Villamil. But, if a gastroenterologist is doing an endoscopy, who is going to monitor vital signs? asks Villamil. The answer, according to McDiarmid and CPT is another health care professional, such as a nurse. However, this doesnt change the fact that pediatricians like Scott feel more comfortable knowing an intensivist is in there with their patient.

The doctors at Munns hospital use a team approach, but also have problems with reimbursement. Most of the time, the pediatrician wants a critical care physician there, says Munn. We use a team approach. Unlike Villamil, Munn isnt billing separately for each physician, so she doesnt have that problem.

But, payment for conscious sedation itself is sometimes difficult, Munn adds. Blue Cross/Blue Shield doesnt recognize conscious sedation codes, she says. They ask for records. The problem appears to be that the insurance companys computer doesnt recognize that the patient is a child, and that is why sedation is necessary for, say, a CAT-scan. The payer doesnt pay any attention to how old a patient is, she explains. We cant even get payers to identify twinshow are we going to get them to recognize age?

The Diagnosis

Villamils final question is what diagnosis code the physician performing the conscious sedation should use. They are not treating the child for the diagnosis for which the procedure is being performed, she says.
But, they still need to use the same diagnosis that the physician performing the procedure uses. What other diagnosis can they use? asks McDiarmid.

The fact is, insurance companies wont pay for two specialists if they both arent necessary. Both have to use the same diagnosis. After all, if the child is having an endoscopy because of abdominal pain, that is the only diagnosis that can be used by anyone involved in the procedure.

Another diagnosis coding problem for these tests is the lack of rule-out codes, says Scott. If I send someone for an x-ray because I want to make sure a bone isnt broken, I cant put a fracture down as the diagnosis, says Scott. I dont know if they have a fracturethats why I want the x-ray. Instead, he has to put down sprain or contusion. The same is true for MRIs and endoscopies, he says. You have to put down the symptom.

Finally, Scott notes that sometimes specialists do too much in the way of exams before and after procedures. He suspects that they may be looking for the extra income. But, when patients are under his care, he doesnt feel its necessary for the specialists to be performing general evaluations. We send kids to a cleft palate team, says Scott. They want to do a developmental evaluation, too. Thats wasted medicine. I give them a referral for everything but a general pediatric evaluation. Do the specialists resent this restriction? Possibly. But I take a little umbrage if they want a referral for an evaluation, he says.