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Cardiology Coding Alert

Develop Standard Practice for Conscious Sedation Billing

Published on Fri Mar 01, 2002

The existence of a CPT code for a procedure or service is no guarantee of reimbursement. No codes better illustrate this point than 99141 (Sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation) and 99142 ( oral, rectal and/or intranasal).
 
Conscious sedation (CS) is used routinely during cardiology procedures, including cardiac catheterizations, cardioversions, transesophageal echocardiography and electrophysiology studies.
 
Unlike general anesthesia, which affects the patient's involuntary functions and requires the presence of an anesthesiologist to monitor the patient, CS allows the patient to enter a state of depressed consciousness yet maintain involuntary functions such as breathing and protective reflexes.
 
Under CS, the patient can also respond to verbal commands or other stimulation. Instead of an anesthesiologist, a trained observer (such as a nurse or physician assistant) must monitor the patient.
 
When CPT introduced the CS codes in 1998, many cardiologists expected reimbursement for the service. That same year, however, CMS announced that CS was included in the accompanying procedure's surgical package. Medicare and Medicaid carriers were quick to enforce this directive.
 
For example, a policy of Empire Medicare Services (the Part B carrier in New Jersey and parts of New York) states that "99141-99142 are a status (B) on the Medicare Fee Schedule Data Base (MFSDB). Therefore, these procedure codes are bundled into payment for other services and are not paid separately."
 
Many private carriers follow Medicare's lead and do not pay for CS. Some cardiology practices may standardize their billing according to Medicare guidelines and not bill any payer for the service, says Savannah Siens, CPC, CCS-P, billing office manager with Northland Cardiology, a 10-cardiologist practice in Kansas City, Mo.
 
"CS may be covered by a few carriers, but most don't pay for it, and it's more efficient to go with one standard of billing practice. If it isn't covered by Medicare, I'm inclined not to report it," she says.
 
Not all cardiology coding specialists share Siens' view: Sueanne Bicknell, RHIA, CPC, CCS-P, director of compliance with Cardiology and Internal Medicine Associates in Dallas, recommends reporting conscious sedation to all non-Medicare payers unless and until specifically directed not to. "CS should be billed to non-Medicare carriers and if they pay it, fine. If they say it is inclusive, the charge should be written off, but you should bill it," Bicknell says. "Every payer is different. The only payer who should not be charged is your local Medicare carrier."
 
Carriers who cover the service usually pay only under the following conditions:

 
  •  A procedure must be performed. When the cardiologist performs a heart cath and uses conscious sedation to anesthetize the patient, this requirement has been fulfilled. Conscious sedation for pain relief typically is not covered.

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  •  In a facility, the cardiologist (not an assistant) must perform the procedure. If the catheterization lab is in the hospital or in another facility, the cardiologist cannot bill for the CS unless he or she personally administers it and documents its use in the catheterization report. If hospital staff or nursing staff administer CS, even though they are under the direction of the physician, the physician cannot bill for the service.

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  •  The physician who performs the procedure must administer the CS. If a second physician assists with the CS during the course of the heart catheterization, it cannot be billed using 99141 or 99142 but, rather, with an appropriate anesthesia code.

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  •  An independent trained observer must help monitor the patient. The observer must be an employee in the practice. This employee is also permitted to administer the sedation, since he or she is operating under the direct personal supervision of the physician.

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  •  Monitoring and evaluations of the patient before and after the sedation was administered must be documented. The patient is monitored closely as CS is administered. The techniques involved in this monitoring, such as pulse oximetry and respiratory and physiologic monitoring, must be documented.
     
    None of the oximetry codes 94760 (Noninvasive ear or pulse oximetry for oxygen saturation; single determination), 94761 ( multiple determinations [e.g., during exercise]), or 94762 ( by continuous overnight monitoring [separate procedure])   may be billed separately, because these codes are a part of CS services.

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  •  The name of the drug, amount and why it was used must be documented, and the record should specifically state that conscious sedation, or IV sedation, was performed. A simple note that the patient received Valium, for example, is not enough.
     
    Unlike most anesthesia codes in CPT 2002, the CS codes are not measured in terms of time. Instead, the appropriate code is selected and reported based on the method of administration (99141 for intravenous, intramuscular or inhalation; 99142 for oral, rectal and/or intranasal). The code may be billed only once per session.
     
    Private payers that cover the service may pay $40-$90, assuming some or all of the criteria listed above are met. Medicare beneficiaries cannot be billed because it is a bundled service.  However, the same does not apply to all private payers. Although Medicare and many private carriers do not pay for conscious sedation, billing the patient directly for the service is not allowed, Bicknell says. She notes that in the Medicare fee schedule, 99141 and 99142 are status B codes, which means they are covered but are bundled into another service (the primary procedure) and, therefore, will not be paid separately. Because the conscious sedation is a part of the primary procedure, it cannot be billed separately to the patient, Bicknell says. 
     
    Note: Because carrier policies on conscious sedation vary, contact your payer to determine if the service may be billed.

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