Pulmonology Coding Alert

Appendix G is your key to understanding which services include CS

If you've struggled with knowing when you should report conscious (or moderate) sedation, the CPT update that takes effect Jan. 1 brings some welcome changes. CPT 2006 now provides definitive guidelines for conscious sedation, along with six new codes to describe the procedure.

As a general rule, if your physician provides both a procedure and conscious sedation (CS), you won't report the sedation separately. All procedure codes that pulmonologists (non-interventionalists) use have moderate sedation built in, says Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta.

Target the 'Bull's Eye'
 
If you see a procedure code with a "dot inside a circle" (which looks a lot like a target "bull's eye") next to it, you'll know that you shouldn't report CS separately with that procedure.

Appendix G of CPT lists all the procedure codes that have moderate sedation built into the code. Instructions contained in Appendix G of CPT explain that certain codes include conscious sedation "as an inherent part of providing the procedure. These codes are identified in the CPT codebook with [the target] symbol." The instructions go on to note that if the same physician provides a "targeted" code and the CS, "it is not appropriate ... to report both the service and the sedation codes 99143-99145."

Targeted codes include many procedures common in pulmonology practices, including bronchoscopies (31622-31629, 31635, 31645, 31646, and 31656), catheter insertion and tube thoracostomy (32019, 32020), and others, Plummer says.

Just the facts: You can't bill separately for 99143, 99144 or 99145 (see "Learn the Ins and Outs of Your New Conscious Sedation Codes" later in this issue for complete definitions of the new codes) if your pulmonologist provides both CS and a targeted service (for instance, 31622, Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; diagnostic, with or without cell washing [separate procedure]).

You Still Need an Independent Observer
 
As in years past, you are required to have an independent, trained observer on hand to help monitor the patient and his level of consciousness, says Denae M. Merrill, CPC, coder for NEM Pulmonary Associates in Saginaw, Mich.

Specifically, documentation should provide proof of the observer's presence and document that the observer monitored the patient's cardio-respiratory functions (pulse oximetry, cardiorespiratory monitor and blood pressure) for the duration of the patient's sedation. In addition, the physician documentation should note a presedation and postsedation assessment.

Setting Matters for 99148-99150
 
You may be able to report 99148-99150 for CS during a targeted procedure, according to instructions in CPT Changes 2006: An Insider's View, but the service must meet two requirements.

1. As required by the code descriptors, a second physician (not the physician providing the service that supports the CS) must provide the sedation.

2. The targeted procedure and the CS must take place in a facility setting (such as a hospital, an outpatient hospital/ambulatory surgery center, or a skilled nursing facility).

Not in the office: You cannot bill for moderate sedation in the physician's office or other nonfacility setting, even if a second (different) physician provides the CS while the primary physician renders the targeted service.

Lack of CS Won't Mean 52
 
Although targeted procedures such as bronchoscopy include CS when provided by the same physician performing the procedure, or when a second physician provides the CS in a nonfacility setting, this does not mean that your reimbursement will fall if the patient is not consciously sedated. CPT specifically states that you need not append modifier 52 (Reduced services), for example, "when the patient does not require sedation."

In other words: You will not gain extra reimbursement for providing CS, but neither will your payment decrease if you don't administer this service. Patient comfort and safety, however, must be priorities when your physician performs any procedure, Plummer says.