Primary Care Coding Alert

Question: When our physician provides moderate sedation in addition to a procedure, some carriers deny the moderate sedation. But if he performs 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. As of Oct. 1, 2007, "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 http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5618.pdf.

Use the article to challenge payers that refuse coverage of moderate sedation when your FP 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.