Radiology Coding Alert

Medicare reimbursement may still be just a dream

If your patients commonly require sedation to help them get through radiology procedures, watch out--your coding options for this service have undergone some important changes in 2006.

“We often use conscious sedation for patients prior to cardiac catheterizations and other interventional procedures to reduce anxiety,” says Carrie Caldewey, CPC, an experienced radiology coder and coding supervisor for Northern California Medical Associates in Santa Rosa, Calif.

What to do: For these sedation services on or after Jan. 1, delete 99141 (Sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation) and 99142 (…oral, rectal, and/or intranasal) from your reporting in accordance with CPT Codes 2006.

In place of these codes, the updated CPT manual introduces a new family of services under the term “moderate sedation,” but don’t let the new name confuse you. Moderate sedation is the same service that you previously reported as conscious sedation--a drug-induced depression of consciousness that allows patients to maintain their airways and ability to respond to stimulation or verbal commands.

Use these codes to report moderate sedation in 2006:

• 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; under 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)

• 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; under 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).

Oust Administration Type as Reporting Criterion

While conscious and moderate sedation are essentially the same procedure, how you report these services will require some adjustments for 2006. Instead of coding your radiologist’s sedation services based on administration method, you will now choose the proper code based on the patient’s age, the providing physician(s), and total “intra-service” time. (See “Knock Out ‘Intra-Service’ Time Confusion for MS Codes” later in this issue).

Coding basics: When your radiologist is serving double duty by providing moderate sedation and performing the primary procedure, you should report one unit of 99143 or 99144 for the first 30 minutes. Choose the most appropriate code based on the patient’s age, and report 99143 for patients under age 5, or 99144 for patients age 5 years or older. Then, for each additional 15 minutes, add on 99145.

Grouping the codes by age “makes sense, because a physician may need to administer sedation to a child in order to keep him still, whereas other patients would most likely not need it,” says Katie Cianciolo, RHIA, CCS, CCS-P, a Wisconsin-based coding consultant.

Missed opportunity: “They probably should have made a determination to also include individuals with developmental disabilities in this category, because you can’t always properly explain a procedure, and sedation may be required even for things like an x-ray,” Cianciolo says.

New option: CPT 2006 also offers a specific code family for when another physician requests moderate sedation services from your radiologist. In such cases, the physician who administers and monitors the sedation can report 99148 or 99149, once again depending on the age of the patient.

Expect Same Old Payment Hassles

Even with new codes and guidelines for moderate sedation, Medicare shocked no one when it designated codes 99143-99150 as “carrier-priced” in its recently released 2006 physician fee schedule. This means that each Medicare carrier can determine how much--if anything--to pay for moderate sedation.

And on the hospital side, Medicare designates the moderate sedation codes as “packaged” services, which means they are not separately payable when provided by the same physician providing the invasive procedure. But don’t give up hope, because not all private payers follow Medicare’s lead.

Good practice: If your practice commonly performs sedation, compare the allowable payment for this service with your current charges while considering a contract with a new payer. Use the negotiations to obtain payment policies supporting moderate sedation compensation.

Calm Your Conscious Sedation Symbol Worries

In 2005, CPT introduced a symbol--a circle with a dot in the center--to indicate procedures that include conscious sedation as an inherent part of the procedure. Coding impact: If you see this symbol next to a code, CPT is telling you not to report conscious sedation separately when the same physician provides the procedure and sedation.

According to the new 2006 CPT guidelines, you can report moderate sedation provided by a different physician  (99148-99150) even for excluded procedures when it’s performed in a facility setting. Remember: Your payer’s guidelines may vary from the CPT rule, so check your payer first.

Opportunity: If you appeal a moderate sedation denial, include any relevant information--such as CPT guidelines on conscious sedation--with your appeal. You should also attach a copy of the relevant payer policy, says Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, HIM program coordinator at Clarkson College in Omaha, Neb. You may also want to make a copy of the codes CPT lists as inclusive of conscious sedation and point out that your code is not on the list.

The CPT manual may list these procedures in an appendix, or you can find them listed in Appendix G of CPT Changes, 2005.