Pediatric Coding Alert

CPT 2006 replaces 99141-99142 with provider, age and time-specific codes

This winter you should stop looking at the administration route to select the correct sedation code and instead focus on three details: the number of non-anesthesiologist providers, the patient's age and the moderate sedation time.

CPT 2006 deletes conscious sedation codes 99141 (Sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation) and 99142 (...oral, rectal and/or intranasal) and replaces them with six new codes, ranging from 99143-99150. "The new system allows the coder to represent the service more accurately using provider, age and time divisions," comments Jack Percelay, MD, MPH, FAAP, immediate past-chairperson of the American Academy of Pediatrics (AAP) Section on Hospital Medicine and pediatric representative to the Board of Society of Hospital Medicine.
 
These fundamentals will prepare you to use the new codes, effective Jan. 1, which include the following:

• CPT 99143 --Moderate sedation services (other than those services described by codes 00100-01999) provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; under 5 years of age, first 30 minutes intraservice time

• 99144--... age 5 years or older, first 30 minutes intraservice time

• +99145--... each additional 15 minutes intraservice time (list separately in addition to code for primary procedure)

• 99148--Moderate sedation services (other than those services described by codes 00100-01999), provided by a physician other than the health care professional performing the diagnostic or therapeutic service that the sedation supports; under 5 years of age, first 30 minutes intraservice time

• 99149--... age 5 years or older, first 30 minutes intraservice time

• +99150--... each additional 15 minutes intraservice time (list separately in addition to code for primary procedure).

1. Think of Conscious Sedation as Moderate Sedation

You can forget the term conscious sedation and start referring to this service as moderate sedation. "Moderate sedation is the most clinically relevant term used to describe the services provided," explains David Jaimovich, MD, section chief of the division of pediatric critical care for Hope Children's Hospital in Oak Lawn, Ill. Therefore, CPT 2006 revises the code family's subhead and guidelines "to reference conscious sedation as the secondary, less preferred term to describe moderate sedation services," wrote Jaimovich in the September 2005 AAP Section on Critical Care Medicine.

The guidelines will define the upper and lower levels of moderate sedation. "Moderate sedation does not include minimal sedation (anxiolysis), deep sedation or monitored anesthesia care (00100-01999)," states CPT's "Moderate (Conscious) Sedation" introductory notes.

2. Answer '1 MD or 2?' to Choose Code Family

Unlike the conscious sedation codes that you assigned by administration route, CPT breaks the new codes into two provider-based groups. You should use the primary code set (99143-99145) "when one physician [with a trained observer] performs both the moderate sedation and the underlying procedure," Percelay instructs.

Example: A child is unable to sit still for a CT scan. The pediatrician provides the imaging study and the moderate sedation. "Because the sedation and procedure involve one physician, you should report the same physician sedation codes (99143-99145)," Percelay says. Don't forget to code the imaging study (such as 74150, Computed tomography, abdomen; without contrast material).

Assign the second family of codes (99148-99150) when the surgery involves two physicians. "One physician performs the moderate sedation in support of another physician who performs the underlying procedure, such as a lumbar puncture or fracture reduction," Percelay explains.
 
Benefit: The breakdown will better define who provides sedation services. Codes 99143-99145 will allow pediatricians who do "their own procedures with anesthesia (conscious or moderate)" to report their role accurately, says Barbara J. Johnson, CPC, MPC, owner of Real Code Inc. in Moreno Valley, Calif.

The latter family of codes (99148-99150) may allow specialists, such as pediatric critical care physicians or gastroenterologists (using a pediatric and adult gastroenterologist), "to utilize two of their physicians and possibly get paid for each doctor's involvement," Johnson points out. One physician performs the procedure while the other provides the moderate sedation (99148-99150).

Important: The two physicians, however, do not have to be in the same specialty, Percelay says. For instance: An orthopedist sets a child's fracture while a pediatrician provides the moderate sedation. The orthopedist would report the fracture care (such as 27808, Closed treatment of bimalleolar ankle fracture, [including Potts]; without manipulation) and the pediatrician should code the sedation (99148-99150). "This coding clearly defines each physician's clinical role," he adds.

3. Identify Patient's Age to Pinpoint Exact Code

Codes 99143-99150 include pediatric-specific codes. Each code family consists of two time-based codes categorized by patient age (younger or older than five years of age). "Distinguishing between under 5 and over 5 is important for the patient," Johnson notes.

You should use the first code in each family (99143 and 99148) for the first 30 minutes of moderate sedation services that a pediatrician provides to a child less than 5 years old. For patients age 5 and older, assign 99144 or 99149.

4. Capture Over 30 Minutes With Add-on Code

Start counting moderate sedation time when the provider administers the sedation agent. The base codes (99143-99144 and 99148-99149) represent the first 30 minutes of moderate sedation services.

Each code family (single physician with trained observer [99143-99145] and two physicians other than anesthesiologist [99148-99150]) contains a single add-on code "to report additional time over the first 30 minutes of intraservice time," Jaimovich notes. For each additional 15 minutes of sedation that a pediatrician provides while she performs the procedure, assign 99145. When the pediatrician provides only the moderate sedation, use 99150 for each additional 15 minutes.

5. Treat All Administration Routes the Same

Despite CPT 2006's provider, age and time additions to coding moderate sedation, one thing remains the same. "The new codes will continue to include all of the six possible routes of administration (intramuscular, intravenous, oral, rectal, intranasal and inhalation)," Jaimovich adds.

6. Bundle 5 Services Into 99143-99150

You should also consider several other services part of moderate sedation. When using new moderate sedation codes, do not separately report these services:

• assessment of the patient (not included in intraservice time)

• establishment of IV access and fluids to maintain patency, when performed

• administration of agent(s)

• maintenance of sedation

• monitoring of oxygen saturation, heart rate and blood pressure

• recovery (not included in intraservice time).

7. Check Payers' Fee Schedules

Although HIPAA requires insurers to adopt CPT codes Jan. 1, payers may choose not to cover 99143-99150. "I won't know the impact the changes will have until we see whether the major HMOs in our area pick up the new codes," says June M. Gerow, RN, CMCN, CCP, coding and compliance supervisor at Golisano Children's Hospital at Strong in Rochester, N.Y.

Good news? If the plans assign enough relative value units (RVUs) to 99143-99150 and pay the base code, as well as the add-on code, the new codes could prove advantageous, Gerow speculates. "Right now, the companies just pay the procedure," regardless of the sedation's length of time.