Cardiology Coding Alert

Cardiologists use conscious sedationsometimes known as IV sedationfor heart catheters. But because many commercial carriers used to allow only anesthesiologists and nurse anesthetists to use CPT anesthesia codes, there is still a lot of confusion among cardiologists regarding their use of such codes. Another difficulty arises because conscious sedation sometimesbut not alwaysis bundled into another procedure.

CPT Assistant defines conscious sedation as sedation with or without analgesia that is used to achieve a medically controlled state of depressed consciousness while maintaining the patients airway, protective reflexes, and ability to respond to stimulation or verbal commands.

Cardiologists can get paid more if they bill properly for conscious sedation services; they also risk being sanctioned if they use the codes inappropriately and overbill as a result, says Sueanne Bicknell, RRA, CCS-P, CPC, reimbursement and compliance auditor with CPR/Heart Place, a 50-physician cardiology group in Dallas, TX.

Because of the widely variable practices in the reporting of conscious sedation, specific new codes were added to CPT in 1998 to describe conscious sedation services.

Codes 99141 (sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation) and 99142 (oral, rectal and/or intranasal) were added to allow for sedation with or without analgesia to be reported by physicians other than anesthesiologists or nurse anesthetists.

But in 1998, Medicare instructed providers not to bill for conscious sedation; since then, Medicare and increasing numbers of third-party payers have considered the sedation as part of a global package, always bundled to the primary procedure. In essence, Medicare and the other carriers are saying that physicians cannot bill for intravenous procedures unless they are performed in the physicians own office. In the hospital, the physician does not own the equipment or the medicine. The physician doesnt administer the IV sedation; rather, he or she has a nurse employed by the hospital do it.

The crux of the billing issues surrounding 99141-99142 is the description in CPT just above the codes themselves that says: The use of these codes requires the presence of an independent trained observer to assist the physician in monitoring the patients level of consciousness and physiological status.

Under the Medicare guidelines, the only time a cardiologist could possibly bill for conscious sedation is if he or she administered the sedation it personally in a hospital setting, itself an unlikely scenario since the cardiologist is too busy performing the primary procedure also to monitor the patients heart and blood pressure.

The cardiologist requires an assistant. In the hospital setting, that helper is employed by the institution.

Some private carriers continue to pay, however, in particular, managed care companies, according to Bicknell. With the situation in such flux, it is more advisable than ever to contact your payer to determine their stand on this issue.

If the procedure is performed in the cardiologists office, and the nurse monitoring the machines is employed by the practice, 99141-99142 can be billed, as long as documentation is provided indicating that the physician personally did all the preliminary work on the patient and administered the IV sedation. The physician also should provide a post-op report that includes any adverse reaction to the sedation. A nurse employed by the practice also is permitted to administer the sedation, since the physician supervises the nurse.

Keeping Accurate Records

Regardless of whether the claim is reimbursed by HCFA or a private carrier, 99141-99142 are listed in the CPT book, which means the sedation procedure must be documented, to record whether the physician or another member in the practice administered it, Bicknell says.

Even though the claim will be denied by Medicare, Bicknell urges continued documentation of the procedures. We charge [conscious sedation] in at $0 and we dont bill Medicare. But we still document it. Good record keeping needs to be complete and thorough, whether you bill or not, she says.