Pediatric Coding Alert

Although many pediatric practices receive denials for conscious sedation, this six-point checklist will improve your bottom line.

1.Code to Reflect Administration

Select a conscious sedation code based on how the drug was administered. When a drug is given intravenously, use 99141 (Sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation). For oral administration, report 99142 ( oral, rectal and/or intranasal).

For instance, suppose a patient who has minor facial lacerations presents to a pediatrician's office. Due to the location of the injury, the child moves continuously, making suturing difficult and risky. So, the pediatrician administers 10 mg of propofol intravenously to sedate the child.

For the laceration repair, report 12013* (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm). The pediatrician adds the three lacerations together. Each laceration is from the same anatomic site (face) and classification (simple). Therefore, CPT guidelines allow reporting the "sum of lengths of repairs for each group of anatomic sites." The wounds are 1 cm, 1.5 cm and 2 cm. The total is 4.5 cm, making 12013* correct.

For the conscious sedation, report 99141. The physician administered the sedative intravenously. Therefore, 99141 accurately describes the administrative technique.

If the pediatrician performs an office visit to assess the child's wounds and any additional injuries, such as head trauma, you should report an office visit (99201-99205, New patient office visit; 99211-99215, Established patient office visit) in addition to the laceration repair. Append the office visit with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to indicate a separate E/M service.

2. Meet Performance Criteria

"Conscious sedation codes are very specific," says Lisa M. Bride, paralegal, Pediatric Management Consultants, Manhattan Beach, Calif. "They are used only when the physician does both the sedation and the procedure."

Therefore, the previous laceration scenario qualifies for conscious sedation codes; the pediatrician administered the propofol and repaired the laceration.

In a contrasting scenario, suppose a pediatric patient who has developmental delays and emotional problems, including claustrophobia and fear of needles, is scheduled for an MRI. The radiologist performs the MRI, and the pediatrician administers ketimine orally.

The pediatrician should bill the appropriate anesthesia code from the 00100-01999 series, and the radiologist would bill for the MRI only. The pediatrician cannot report conscious sedation, because he has not met the performance qualifications. Similarly, the radiologist cannot report the conscious sedation because she did not administer the drugs.

The pediatrician bills 01922 (Anesthesia for non-invasive imaging or radiation therapy) "with modifier -52 (Reduced services) to reduce the fee because the case did not require general anesthesia," says Barbara Johnson, CPC, coder with Loma Linda University Anesthesiology Medical Group Inc. in Loma Linda, Calif.

"Even though insurance companies can oftentimes give pediatricians a hard time when they use these codes, it is the accurate way to bill that scenario, and the denial is appealable," Bride asserts.
 

3. Adhere to Monitoring Guidelines

"The pediatrician performing the procedure must have a 'qualified person' monitor the patient," Johnson says. "The qualified person can be a registered nurse, nurse practitioner, or other qualified health personnel."

For pediatric observers, The American Academy of Pediatrics guidelines require training in pediatric basic life support and strongly encourage training in pediatric advanced life support.

"Conscious sedation includes pre- and postsedation evaluation of the patient, administration of medications and monitoring of cardiorespiratory function," Johnson explains.

4. Charge Applicable Parties

Although many third-party carriers previously denied conscious sedation, they have been expanding their coverage. On Jan. 25, 1999, Wellmark Blue Cross & Blue Shield (BC/BS) of Iowa and South Dakota reversed its decision to deny conscious sedation codes as "an integral part of another procedure" and will now "allow reimbursement for these two codes." Although not all carriers will pay for conscious sedation, until you know each insurer's policy you should code for the service.

Payers who adopt Medicare guidelines will probably not pay for conscious sedation. Medicare designates conscious sedation (99141-99142) as a status B on the Medicare Fee Schedule Data Base (MFSDB), meaning the service is bundled into the primary procedure. Because the cost of conscious sedation is factored in to the relative value units (RVUs) of a procedure, no separate payment will be made.

Heads up: The American Medical Association resource based relative value scale review update committee (AMA RBRVS RUC) is examining the conscious sedation issue. They are looking at when conscious sedation is inherent in the procedure and which codes consider conscious sedation an add-on service when provided. They will then make their recommendation to Medicare, which will make a final policy decision.

5.Bill for Supply

Regardless of payer, when conscious sedation is administered in the office setting, you should bill for the supply. Report the applicable procedure codes and the appropriate supply code.

For example, consider a child who falls while skateboarding and requires a closed wrist reduction. The boy is highly combative and refuses to hold still. The doctor injects intramuscularly 1 mg of Versed into the patient to induce conscious sedation.

You should report the fracture treatment with 25605 (Closed treatment of distal radial fracture [e.g., Colles or Smith type] or epiphyseal separation, with or without fracture of ulnar styloid; with manipulation).

The pediatrician probably assessed other injuries and incorporated medical decision-making to determine whether he could treat the wrist in the office. If documentation proves that a separate service was performed from the fracture treatment, assign the appropriate office visit code appended with modifier -25.

For the intramuscular conscious sedation, report 99141. Report the Versed with J2250 (Injection, midazolam HCl, per 1 mg). In the example above, the doctor delivered 1 mg, so report J2250 once.

Facilities include the cost of supplies, medications and other services in their fee, so do not bill for the supplies in the hospital or facility setting. For the previous MRI example, the hospital would bill for the ketimine.

List the primary reason for the visit first, followed by associated services. The child came into the office for the wrist pain, so report the manipulation first. The next main service is the examination. Let's say documentation supported a level-three office visit and the child is an established patient. So, assign 99213 next. Finally, list the conscious sedation, followed by the supply code.

The claim form should read:

Note: Ask carriers for their policies on reporting multiple codes and the order in which to list them.

6. Attach Documentation

"Two out of three conscious sedation claims are denied," Bride estimates. "Insurance companies may not understand that small children or more difficult children may need sedation for procedures that most adults could tolerate without analgesia."

Explain the extenuating circumstances that necessitated conscious sedation. Bride encourages "physicians to be proactive and not wait until they get the denial." Copy the supporting documentation to the claim with a quick note on the HCFA-1500 saying, "See attached documentation."

"Those steps will ensure that your claim is not denied," Bride counsels. In fact, Bride says that submitting initial documentation with the claims has resulted in a 100 percent success rate for her clients in obtaining reimbursement for conscious sedation.

According to CPT Assistant July 1998, documentation should include:

* The notation should include the medication, dosage and administration used. A note that reads, "The patient was given Versed" is insufficient. Instead, documentation should state, "Conscious sedation (99141) with 1 mg of Versed was given."

* You should also include the conscious sedation start and stop time and a note that a trained observer was present.

Note: Pulse oximetry (94760-94762) is included in conscious sedation and should not be reported separately.