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Updated definitions, coding for conscious sedation

Radiology Administrator's Compliance and Reimbursement Insider, May 1, 2006

by William Malm, ND, RN

Radiologists continue to struggle with how to define and bill conscious sedation. Below are updated guidelines, definitions, and coding suggestions for outpatient prospective payment system hospitals.

Define anesthesia

Providers deliver anesthesia by many methods, so it’s important for coding purposes to understand the accepted terms used to define these methods and levels of sedation. The American Society of Anesthesiolo-gists House of Delegates approved the following levels in October 1999:

  • Minimal sedation (anxiolysis): Cognitive function and coordination may be impaired. Patients re-spond normally to verbal commands. There is no effect on cardiovascular or ventilatory functions.
  • Moderate sedation/analgesia (conscious sedation): Depression of consciousness in which pa-tients respond purposefully to verbal commands. No intervention is required to maintain airway or spontaneous respirations, and there is no effect on cardiovascular function.
  • Deep sedation/analgesia: Depression of consciousness during which patients cannot be easily aroused. Ventilatory function may be impaired without a change in cardiovascular function.
  • General anesthesia: Drug-induced loss of consciousness; patient is not arousable even to painful stimuli. Patients generally require ventilatory assistance, and cardiovascular function may be impaired.
  • Monitored anesthesia care (MAC): Separate from the four levels of anesthesia and does not describe the depth of sedation listed above. MAC describes a specific anesthesia service requested by the operating physician of the anesthesiologist. The latter participates in the care of the patient undergoing a diagnostic or therapeutic procedure.

    During MAC, the anesthesiologist may monitor vital signs, perform maintenance of the patient’s airway, administer sedatives, analgesics, or other medications as necessary, and assist with other problems. For example, an elderly patient who has chronic obstructive pulmonary disease may require an anesthesiologist to ensure cardiovascular and respiratory integrity.

    Note 2006 definition, billing changes

    The American Medical Association (AMA) recently released new coding guidelines for conscious sedation, which took effect January 1. Note that conscious sedation does not include minimal sedation, deep sedation, or general anesthesia. The charge for conscious sedation includes the following elements (therefore, do not bill these elements separately):

  • Assessment of the patient
  • Establishment of IV access
  • Administration of agent(s)
  • Maintenance of sedation
  • -Monitoring of oxygen saturation, heart rate, and blood pressure
  • Recovery

    (Source: CPT Changes 2006—An Insider’s View,
    p. 270–274, AMA.)

    The AMA deleted codes 99141 and 99142 and replaced them with six new codes, 99143–99145 and 99148– 99150. The AMA then divided these new codes into the following two groups (note that physicians do not include anesthesiologists):

  • -Single physician with a single observer (99143– 99145)
  • -Two physicians with a single observer (99148– 99150)

    The AMA also broke physicians into the following two categories for the purpose of billing the proper code:

  • -One physician (i.e., the physician performing the procedure) and one trained observer (e.g., a nurse)
  • -Two physicians (i.e., the physician performing the procedure and a second physician, who provides the moderate sedation within a facility setting)

    The codes no longer refer to the route of administration; instead, they reflect the level of physician-involvement stated above, the patient’s age, and the time of sedation. Note that the time of sedation does not include assessment or recovery time. Rather, the AMA defines the time of sedation as the “time of the administration of the sedation agent, [which] requires face-to-face attendance and ends at the conclusion of personal contact by [the] physician providing the sedation.” (Source: CPT 2006 manual, p. 409, AMA.)

    Many providers are also confused about when they should code and bill conscious sedation. CMS has stated that certain procedures include conscious sedation, meaning that it is inherent to the procedure and therefore not separately billable. The CPT 2006 manual lists these procedures in Appendix G and also includes a bull’s-eye symbol to the left of the specific CPT code descriptions within the book.

    You will find almost all of the bull’s-eye procedures listed in specific areas in the CPT 2006 manual because sedation is inherent in certain types of procedures. For example, bronchoscopy, gastrointestinal/endoscopy procedures, and most of the cardiac catheterization and interventional radiology procedures are included in Appendix G and have bull’s-eyes next to their descriptions.

    Appendix G contains radiology codes 77600, 77605, 77610, and 77615 for hypothermia during radiation treatments.To prevent denials, teach radiology professionals in your hospital to review Appendix G for a surgical component code. For example, a balloon angioplasty of the iliac artery (35473) is a procedure that includes moderate sedation. Therefore, do not bill separately for conscious sedation in this instance.

    Learn how to code conscious sedation

    From a chargemaster, coding, and billing perspective, hospitals face a dilemma: How are they to capture charges for conscious sedation? CPT codes 99143– 99150 have a status indicator N, meaning that their reimbursement is packaged within the procedure. Here are some guidelines to follow:

  • For procedures listed in Appendix G of the CPT 2006 manual, include the cost of the delivery of the sedation within the charge for the procedure. For procedures not found within Appendix G, your facility must determine how to record and bill these codes.
  • CMS instructs facilities to represent the sedation charge (even though it is packaged) on the claim when the sedation is not associated with a procedure listed in Appendix G. CMS requests that you include these codes on the claim for reporting purposes, when applicable. This will require significant coordination and training to use these conscious sedation codes correctly.

    Although CMS requires hospitals to record these procedures, many facilities have opted to not charge or bill for conscious sedation at all. Therefore, they have built the cost of the conscious sedation delivery into the price of the procedure. These hospitals reason that this does not result in overpayment and therefore does not represent a compliance concern, whereas the inaccurate reporting of bundled codes does.

    How to record and bill for conscious sedation is truly a facility-specific decision. Make this decision in conjunction with the appropriate compliance professionals within your organization. For further clarification and guidance, consult your fiscal intermediary.

    Insider source

    William L. Malm, ND, RN, Health Revenue Integrity Services, Cleveland, OH, 440/331-3312.