Primary Care Coding Alert

Coders say some insurers are paying for sedation
 
Do you report moderate (or conscious) sedation when your FP performs this service on a patient? If you do not, you-re not alone -- but you could be losing out.
 
Many carriers are still not reimbursing for the service, which CPT anointed with a new code set in 2006. So coders may wonder why they should put forth the time and effort to correctly code these services.
 
But leaving these codes off the claim could be a mistake because some insurers have started paying for moderate sedation, says Robert LaFleur, MD, of Medical Management Specialists in Grand Rapids, Mich.
 
-Reimbursement for moderate sedation has been spotty,- LaFleur concedes. But he goes on to say that some payers have started paying for certain types of moderate sedation.
 
And Medicare designated these codes as -carrier priced- to gather utilization and proper pricing information. -Many Medicare carriers are beginning to recognize moderate sedation,- says Michael Granovsky, MD, CPC, president of MRSI, a coding and billing company in Woburn, Mass. So although you may not get paid every time you report moderate sedation, you should include it on the claim when you-re allowed to.
 
Benefit: The more times an insurer sees moderate sedation codes on claims, the more likely it will consider paying for the service in future policy decisions.
 
If you are confused about coding for these services, check out this primer on the ins and outs of moderate sedation coding.
 
Use 99143-99145 When Physician Performs Procedure, Sedation
 
There are two sets of moderate sedation codes, which are separated based on the number of physicians involved.

You-ll choose from one of these codes when the same physician performs the sedation and the procedure (or service), says Cheryl Tereba, a manger of revenue recovery for UMass Memorial Healthcare in Worcester:

 - 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; younger than 5 years of age, first 30 minutes   intra-service time

 -  99144 -- - age 5 years or older, first 30 minutes intra-service time

 -  +99145 -- - each additional 15 minutes intra-service time (list separately in addition to code for  primary service).
 
Remember: When using moderate sedation codes, you must be sure the medical record contains a thorough explanation of the medical necessity for performing this sedation service.

Don't Code Separately for Establishing IV

When providing moderate sedation, you cannot report the following services separately:

 -  Patient assessment (not included in intraservice time)

 -  Establishing 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).

Remember: Intraservice time starts with the sedative agent administration, requires continuous face-to-face attendance and ends at the conclusion of personal contact by the physician providing the sedation.
 
To illustrate proper use of these codes, consider this example from LaFleur:
 
A 30-year-old established patient presents with a new problem, a pilonidal abscess that requires drainage. The area is tender, and the patient is apprehensive.
 
After conducting the initial history and exam, the physician decides that the patient won't tolerate treatment well without sedation.
 
The physician supervises the nurse while she performs administration and induction of an intravenous sedating agent without an analgesic. This makes the patient sleepy but responsive to commands. The physician then incises, drains and packs the abscess. The entire procedure takes 20 minutes.
 
In this scenario, you should code for moderate sedation. Your claim should look something like this:

 - 10080 (Incision and drainage of pilonidal cyst; simple) for the abscess drainage.

 -  the appropriate E/M code (99211-99215) based on the encounter specifics. 

 -  modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on
the same day of the procedure or other service) attached to the E/M code to show that the drainage and E/M were separate services.

 -  99144 for the sedation.

 -  685.0 (Pilonidal cyst; with abscess) linked to 10080, the E/M code and 99144 to prove medical necessity for these procedures.
 
2-Physician Encounters Call for Different Set of Sedation Codes
 
Sometimes, a physician asks another physician to provide moderate sedation while he provides the service (or performs the procedure). This scenario is rare in a family medicine office. But if this occurs, Tereba says, you should choose from the following codes:

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

 -  99149 -- - age 5 years or older, first 30 minutes intra-service time

 - +99150 --  - each additional 15 minutes intra-service time (list separately in addition to code for primary service).

Remember: As with all claims containing moderate sedation codes, check the medical record for a thorough explanation of the medical necessity for this service.

Leave Sedation Codes Off -Targeted- Procedures

If you-re considering a conscious sedation code, you should observe one important restriction: If the code for the procedure has a target symbol next to it in the CPT manual, you cannot report conscious sedation along with the code unless two providers are involved and it occurs in a facility setting, Granovsky says. If you report a conscious sedation code from the single physician set (99143-99145) along with a 8 code, you-ll receive a denial.
 
(Note: There is a list of "target symbol" codes in Appendix G of CPT 2007, under the heading -Summary of CPT Codes That Include Moderate [Conscious] Sedation.-)
 
Exception: There is one scenario in which insurers may allow you to report a conscious sedation code in addition to a 8 code. If the encounter occurs in the facility setting (for example, a hospital) -- and one physician performs the procedure and a second physician provides the sedation -- you can report 99148-99150 along with an Appendix G-listed procedure code, Granovsky says.
 
But encounters of this sort are not that common, according to LaFleur. -CPT suggests that needing a second physician for any of the -targeted- procedures is unusual,- he says.