Pediatric Coding Alert

Question: Our pediatric group typically bills 99214-25, 93000 and 99141 for services and procedures performed in the office on the same day. When we bill 99141 or 99142 (conscious sedation), Blue Cross Blue Shield, United Healthcare and Aetna deny 93000 (12-lead ECG). They pay the sedation code, but bundle 93000 with 99141/99142. What is the proper way to bill the session?

Tennessee Subscriber

Answer: An electrocardiogram (ECG) (93000, Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report) normally does not require conscious sedation (99141, Sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation; and 99142, oral, rectal and/or intranasal). Therefore, if extenuating circumstances exist, such as the child's inability to hold still for the ECG, you should clearly document the medical necessity for 99141-99142.

Otherwise, although you billed the procedures correctly, the third-party payers that you mention probably consider conscious sedation part of the surgical service. They erroneously reversed their edits, however, and paid for the sedation rather than the ECG. Many insurers bundle 99141 and 99142 because they include the payment for the sedation in the relative value units for the primary procedure, such as 93000.

For instance, Blue Cross Blue Shield of Tennessee lists 99141 and 99142 as bundled services. Although the company states that the codes are billable, they will reimburse them at $0.00 because they are "included in the reimbursement for the procedure or service to which it is incident." They note that they base this policy on the Medicare Physician Fee Schedule, which identifies 99141 and 99142 as status "B," services that are considered bundled regardless of where they are performed. Although pediatricians normally don't have Medicare patients, your other insurers probably adopted Medicare's policies.

Coverage may also depend on who provides the sedation services. Many plans indicate that they will not pay for 99141-99142 when the primary surgeon performs conscious sedation. In contrast, some payers, such as Wellmark Blue Cross Blue Shield of Iowa, allow payment if a provider other than the surgeon performs anesthesia services. In this case, you should use the appropriate anesthesia codes, such as 01992 (Anesthesia for diagnostic or therapeutic nerve blocks and injections [when block or injection is performed by a different provider]; prone position), rather than the conscious sedation code. The National Correct Coding Initiative, however, bundles 01992 with 93000. So if the insurer follows the edits, you will not receive separate reimbursement for the anesthesia.

Due to all these variations, you should contact your payers, verify their policies and check if their edits are incorrect. In addition, resubmit the claims requesting payment for 93000. If you still code the sedation, enter it at a zero dollar value and inform the insurer that you understand that this service is bundled into the ECG. Consequently, you expect payment for the procedure but not the sedation.