Pediatric Coding Alert

Question: When I provide moderate sedation in addition to a procedure, such as a spinal tap, some carriers deny the moderate sedation. But if I perform only the procedure and another physician provides the sedation, we each get paid for our services. What's going on?


New Jersey Subscriber

Answer: The insurer may be following the soon-to-end Medicare policy that pays for moderate sedation only when one physician performs the procedure and another physician sedates the patient (99148-99150, Moderate sedation services ... provided by a physician other than the healthcare professional performing the diagnostic or therapeutic service that the sedation supports ...).

Medicare has not covered 99143-99145 (Moderate sedation services ... provided by the same physician performing the diagnostic or therapeutic service that the sedation supports ...), codes for sedation that a single physician performs in addition to the procedure.

Good news: Those denials might become a thing of the past. Beginning Oct. 1, "Physicians who both perform, and provide moderate sedation for, medical/surgical services will be paid for the conscious sedation consistent with CPT guidelines," according to MLN Matters Number: MM5618 available at www.cms.hhs.gov/MLNMattersArticles/downloads/MM5618.pdf.

Use the article to challenge payers that refuse coverage of moderate sedation when your pediatrician provides it in addition to a procedure that does not include sedation, such as a spinal tap (62270, Spinal puncture, lumbar, diagnostic) with same-physician sedation (99143-99145). But CMS has not assigned relative value units (RVUs) for these services.