Primary Care Coding Alert

Question: What are Medicare's payment policies for the new moderate (conscious) sedation codes? Can we receive payment for any of the sedation codes?

Alabama Subscriber

Answer: There has been some movement on the moderate sedation payment front, but collecting dollars for the services will still be difficult.

Historically, Medicare carriers only paid for 99148-99150 (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 ...), the moderate sedation codes that cover a situation in which one physician performs a procedure and another physician sedates the patient.

But starting Oct. 1, 2007, Medicare instructed its carriers to cover and pay for 99143-99145 (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 ...), the moderate sedation codes that cover sedation that a single physician performs in addition to the procedure.

"Physicians who both perform, and provide moderate sedation for, medical/surgical services will be paid for the conscious sedation consistent with CPT guidelines. However, if the physician performing the procedure provides local or minimal sedation for the procedure, then no separate payment is made for the local or minimal sedation service," according to MLN Matters transmittal No. MM5618.

(Find the article online at www.cms.hhs.gov/MLNMattersArticles/downloads/MM5618.pdf.)

The moderate sedation codes are still carrier-priced, which means every Medicare carrier is free to value them as they will. According to the transmittal, Medicare assigned the 99143-99145 codes a "C" status indicator under the Medicare physician fee schedule, meaning that "CMS has not established relative value units (RVUs) for these services," Medicare states.

Hope for future pay: As long as these codes are status "C," carriers have discretion on what amount to pay for them. However, this step means that Medicare may add RVUs to all of the moderate sedation codes in 2008 (or at some other time soon).