Feeling Hazy about ED MCS Coding?

Get Out of the Fog with Coding Tools of the Trade

By Sarah Todt RN, CPC-EDS

Emergency department (ED) physicians are armed with tools to provide adjunct care to typical evaluation and management (E/M) services. Frequently, ED care involves procedures that are easily performed with, or require, moderate conscious sedation (MCS).

New medications allow ED physicians to safely provide sedation services. These medications provide analgesia as well as muscle relaxation, and the combination of these medications allow the physician to perform ED procedures that previously required full anesthesia in an operating room. A clear understanding of ED sedation services is essential for properly identifying appropriate codes for MCS services.

Level of Sedation Determines Services

ED physicians determine sedation services based on the procedure performed and the clinical status of the patient. The categories of sedation services vary depending on the patient’s response to the drugs and necessary support. The level of sedation achieved, ranging from mild anxiolysis to deep sedation and anesthesia, represents the type of sedation service performed.

Relieve the Stress with Anxiolysis

Anxiolysis means relief of anxiety. Anxiolysis includes medications such as Ativan and Valium, and allows the patient to respond normally to verbal commands. Anxiolysis is frequently performed in the ED, is not considered MCS, and is bundled into the E/M service.

Deep Sedation Falls Into Anesthesia

At the other end of the spectrum is deep sedation. With deep sedation, the patient will not respond to verbal stimulation but may respond to repeated painful stimulation. With this deep sedation, respiratory support is frequently required. This is outside the definition of MCS and falls into an anesthesia service.

Breathe Easy with MCS

MCS has a distinction from anxiolysis and deep sedation, according to the Medicine section in CPT®. With MCS, the patient responds to verbal commands followed by light tactile stimulation and  maintains breathing and cardiovascular function without intervention. MCS includes services such as: establishing intravenous access, administering medication, maintaining sedation, and monitoring oxygen saturation, heart rate, and blood pressure.

Know the Two MCS Types

The two types of MCS are:

  • Provided by the same physician performing the sedation supported diagnostic or therapeutic service
  • Provided by a physician other than the one performing the sedation supporting therapeutic service

Both code sets are further delineated based on the patient’s age and duration of service. Codes are available in each code set for ages under five years with separate codes for five years and older.

The first type of MCS is provided when the physician performs both the procedure and the supporting MCS. There is a requirement for the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status. Some procedures bundle MCS into the service when performed by the same physician. They are identified in CPT® with a ¤ symbol and are listed in Appendix G. CPT® codes to use for these services are below:

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)

The second type of MCS is used when the physician performs supportive MCS for another physician’s procedure. The second physician may be of another specialty or may be another ED physician. This type of MCS may not be reported when the second physician is a resident physician under the supervision of the physician performing the procedure. This type of MCS may be reported in a facility setting, such as the ED, along with procedures listed in Appendix G. CPT® codes for these services include the following:

99148
Moderate sedation services (other than those services described by codes 00100-01999), provided by a physician other than the health care professional performing the diagnostic or therapeutic service that the sedation supports; younger than 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)

Timing is Everything with MCS

The timing of the service is referred to as the intra-service time. According to CPT®, “Intra-service time starts with the administration of the sedation agent(s), requires continuous face-to-face attendance, and ends at the conclusion of personal contact by the physician providing the sedation.” Each code set has two primary codes based on the age of the patient and is used to report the initial 30 minutes of intra-service time. Service time exceeding the 30 minutes is reported with a category specific add-on code. Code 99145 is used to report each additional 15 minutes of intra-service time in addition to the primary codes 99143 or 99144, and code 99150 is used to report each additional 15 minutes of intra-service time in addition to the primary codes 99148 or 99149.

MCS at Work

Example 1: MCS in support of the physician’s own procedure

A 40-year-old patient presents to the ED complaining of shoulder pain after falling from a ladder. The patient is diagnosed with an anterior shoulder dislocation and the ED physician performs the shoulder dislocation under MCS. The intra-service time is reported as 50 minutes. The MCS is reported with 99144 and 99145.

Example 2: MCS in support of another physician’s procedure

A four-year-old patient presents to the ED with a complex facial laceration after falling from a tricycle. A plastic surgery specialist is consulted to repair the wound and requests the emergency medicine department physician performs the MCS. Intra-service time is 25 minutes. The MCS is reported with 99148.

Appendix G

Procedure codes having the symbol ¤ direct that MCS not be reported in addition to the procedure. Consult Appendix G’s list of codes considered to have MCS bundled into the procedure when the procedure and MCS are performed by the same physician. Procedures representing Appendix G codes most frequently performed in the ED include, but are not limited to: chest tube insertion (32551 Tube thoracostomy, includes water seal (eg, for abscess, hemothorax, empyema), when performed (separate procedure); pericardiocentesis (33010 Pericardiocentesis; initial); transvenous pacer insertion (33210 Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter (separate procedure); and central line in patient less than five years of age (36555 Insertion of non-tunneled centrally inserted central venous catheter; younger than 5 years of age); PICC line in patient less than five years of age (36568 Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump; younger than 5 years of age); transcutaneous pacing (92953 Temporary transcutaneous pacing); and elective cardioversion (92960 Cardioversion, elective, electrical conversion of arrhythmia; external).

Be Clear on the Coder’s Role

MCS is an important service provided by ED physicians. Accurately capturing MCS services requires a clear understanding of sedation code differences to assign MCS codes properly.

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