Radiology Coding Alert

You may be in the habit of ignoring moderate sedation codes when your radiologist provides the service to a patient. But a new CMS transmittal means you need to reconsider your old ways because a reimbursement change could be in the works.

Old way: Previously, carriers would only pay for 99148-99150, which cover one physician performing a procedure and another physician sedating the patient. Carriers would not cover 99143-99145, which describe sedation a single physician performs in addition to the procedure.

New way: Now Medicare appears to be saying that carriers should pay for 99143-99145 when the same physician performs a procedure and sedation with a trained observer present, says Margaret Loftus, a coder with Stanford Hospital and Clinics in Palo Alto, Calif.

Watch out: You can't bill 99143-99150 with the codes listed in CPT's Appendix G because those codes include conscious sedation.

The source: A recent CMS transmittal allows carriers to pay for both types of sedation. "The new policy is as follows: If the physician performing the procedure also provides moderate sedation for the procedure, then payment may be made for conscious sedation consistent with CPT guidelines," says Transmittal 1316 (Change Request 5618.) You can read a summary in MLN Matters article 5618 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5618.pdf.

Carriers now have the OK from Medicare to process these codes for payment, says Marvel Hammer, RN, CPC, CHCO, with MJH Consulting in Denver. But she cautions that Medicare states carriers "may" -- not "must" or "should" -- reimburse.

The new transmittal gives "no guidance at all as to payment," Loftus adds. "The codes are carrier-priced, which means every Medicare carrier is free to value them as they will." And as long as these codes are "Status C," the carriers have discretion on whether to pay for them.

Important: Make sure your documentation specifies the sedation "level," Hammer says. The transmittal makes clear that you shouldn't bill 99143-99145 for local anesthetic or minimal sedation.

Example: An elderly patient is extremely nervous and unable to remain still for an x-ray prior to her procedure. Your physician provides and documents both the x-ray and the moderate sedation. Because the sedation and procedure involve one physician, you should report the same-physician sedation codes (99143-99145).