Gastroenterology Coding Alert

Regardless of payer, you must meet the criteria CPT sets forth in CPT Assistant July 1998 for reporting conscious sedation:

Documentation must show that conscious sedation was performed, including pre- and postsedation patient evaluations. The physician who performs the colonoscopy must also administer conscious sedation.

"It would be impossible for the doctor to stop performing the procedure to administer the drugs," says Sandi Scott, CPC, CORT, director of coding at Mission Internal Medical Group, a practice with four gastroenterol-ogists in Mission Viejo, Calif. Because the physician is overseeing the dosages, supervising the administration, and monitoring the patient, CPT's criteria are met. "We've had no problems with being paid for this interpretation," she says. An "independent, trained observer" must be present to monitor the patient throughout the procedure. A nurse usually qualifies for the position. The patient's cardiorespiratory functions (pulse oximetry, cardiorespiratory monitor and blood pressure) must be monitored. The notation should include the medication, dosage and administration used. A note that reads, "The patient was given Versed" is insufficient. Instead, documentation should state, "Conscious sedation (99141) with 1 mg of Versed was given."

You should also include the anesthesia start and stop time and a note that a trained observer was present. Note: Pulse oximetry (94760-94762) is included in conscious sedation and should not be reported separately.