Pediatric Coding Alert

Along with vaccine administration, another bundling edit that affects mainly pediatric subspecialists (and other internal medicine physicians) involves conscious sedation codes 99141 and 99142, which are being bundled with various procedures. But according to CPT conventions, conscious sedation should be coded and paid for when performed in certain situations.
 
There are two main ways to determine whether conscious sedation is included in a CPT code, says Linda Walsh, senior health policy analyst with the AAP division of healthcare finance and practice. One is standard of practice, and the other is to go over each CPT code and see if the original RVU included conscious sedation.
 
Standard of practice: If it is the standard of practice to administer conscious sedation with a certain procedure, then an extra fee would not be warranted. For example, colonoscopies are always performed with conscious sedation, so no conscious sedation code would be warranted. But for laceration repair, conscious sedation isnt usually performed. If conscious sedation is inherent in the procedure, it will probably be included in the main code, Walsh says. If its not built in, the physicians can charge extra.
 
RVU evaluation: The AMA relative-value update committee (RUC) is now going through a major evaluation of various codes, trying to determine which include conscious sedation in the valuation, Walsh says. Look to future issues of Pediatric Coding Alert for further coverage of this issue.
 
The conscious sedation bundling will get some needed attention this year on a national level, promises Joel Bradley, MD, FAAP, the incoming CPT Codes advisor for the AAP. Reimbursement policy is complicated because CMS decided some time ago not to pay for conscious sedations.

When To Bill Separately

 
According to Bradley, conscious sedation should be billed if it is not typically done with a particular procedure. For example, if one usually sutures without conscious sedation, but on one occasion uses sedation for a given child, it would be appropriate to code the conscious sedation and the laceration repair together, he says. On the other hand, when the procedure is typically done with conscious sedation, as in endoscopy, then the relative value established in the fee schedule will probably have the payment bundled in, and no separate billing is needed.
 
Bradley bills conscious sedation on occasion, but he always has to submit a separate report. Sometimes we win, he says. But it is difficult to assign a value to the codes in practice. You encounter different time frames and thus expend variable resources each time conscious sedation is provided. The anesthesia codes get around this by factoring in time units, but the conscious sedation codes are, as Bradley says, one size fits all.