Urology Coding Alert

If you've been struggling to get paid for the conscious (moderate) sedation your urologist provides during procedures such as vasectomies, there's good news: CMS gave Medicare carriers the go-ahead to start paying for more moderate sedation codes late last year.

The downside: Permission to pay doesn't necessarily mean you'll see reimbursement. Here's the scoop on what you need to know to ensure you're capturing every dollar possible for moderate sedation claims.

Old way: Before October 2007, 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 ...), codes that cover a situation in which one physician performs a procedure and another physician sedates the patient.

Most carriers wouldn't cover 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 ...), codes that cover sedation that a single physician performs in addition to the procedure.

New way: But beginning Oct. 1, "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 transmittal MM5618.

Your urologist may opt to give the patient moderate sedation during in-office procedures such as needle biopsies of the prostate, cystoscopy, fulgurations and removal of small bladder tumors.

Note: Depending on your state's regulations, your practice may need accreditation to administer conscious sedation in the office.

The new language is a "positive sign" and indicates that Medicare is responding to providers' letters in support of moderate sedation, experts say.

Good news: "Carriers now have the directive from Medicare to process moderate sedation codes for payment," says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver.

Bad news: In the 2008 Medicare Physician Fee Schedule, CMS still gives no guidance about payment. The codes remain carrier-priced. While Medicare Transmittal 1324 clearly states that carriers are to process compliantly reported moderate sedation services for payment, the transmittal is mute on the allowed reimbursement.

As long as these codes are "Status C," carriers will continue to have the discretion to determine the payment amount. Whether to pay at all is up to each carrier, says Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 31-urologist, two-urogynecologist practice in Indianapolis. "It is also priced by the carrier, so we really have a moving target here."

Providers can hope for the "best-case scenario" for 2009, in that Medicare may actually add relative value units (RVUs) to all of the moderate sedation codes, Hammer adds. This may also encourage other non-Medicare payers to recognize reimbursement for these services.

When reporting moderate sedation codes 99143- 99150, make sure your documentation specifies the level of sedation, Hammer says. The Medlearn Matters article stresses that carriers can pay for the conscious sedation when they perform the sedation and the procedure. "However, physicians who perform and provide local or minimal sedation for these procedures will not be paid separately for the sedation services," the article says.

Watch out: "In the back of your CPT book in Appendix G is a list of codes that include 99143-99145. Any code on this list cannot be billed with 99143-99145," says Nancy Perry, billing coordinator for the urology department at University of Toledo Physicians in Ohio. You should never report 99143-99145 with the codes listed in CPT's Appendix G because those codes include conscious sedation in their descriptors or assigned relative value units.

Important: Make sure your documentation specifies the level of sedation, and be certain that the urologist provides moderate sedation before coding it. "Documentation requirements will probably vary by carrier, but I would think the minimum would be the ASA (American Society of Anesthesiologists) score, the dosage, the length of time, and the documentation of an observer, as described," Hause says.

Confused about what constitutes moderate sedation? Check out this definition: "Moderate sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation," according to Medicare.