Gastroenterology Coding Alert

Some insurers will pay separate conscious sedation codes It's a fact: When the gastroenterologist administers conscious sedation during an endoscopic procedure, most carriers will not pay for the sedation separately.
 
However, the key word in that phrase is "most" - you'll often hit the brick wall of denial when separately reporting conscious sedation (99141, Sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation) during an endoscopic procedure. But with some research and the right coding, you may find some private carriers among your stable of insurers that will reimburse separately for sedation. Medicare Won't Recognize Separate Sedation The most important thing to remember about conscious sedation? Never report it separately when filing an endoscopic procedure claim to Medicare. The Office of the Inspector General (OIG) may well see that as fraudulent.
 
Example: Let's say a patient reports to the office with sensitivity in her entire abdomen. The physician performs a diagnostic upper gastrointestinal EGD with conscious sedation. When coding this scenario for a Medicare patient, you should:

  report 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the    duodenum and/or jejunum as appropriate; diagnostic,   with or without collection of specimen[s] by brushing   or washing [separate procedure])

  link the ICD-9 code 789.67 (Abdominal tenderness; generalized) to 43235. Why can't I report the sedation? Medicare already figures the cost of the conscious sedation when it calculates the relative value units (RVUs) for 43235, according to experts. To report the sedation separately would be double-billing.
 So forget about putting a conscious sedation code on an EGD claim for a Medicare patient. There are possibilities for reimbursement from other payers, though. Persistence Pays Off With Private Insurers "It's a challenge" to get conscious sedation reimbursement, concedes Lois E. Curtis, CPC, insurance/billing manager for Gastroenterology Associates in Evansville, Ind. But aided by smart research techniques, Curtis and her coding colleagues were able to secure conscious sedation reimbursement from several independent payers.
 
Read on for some advice on how to find out which payers won't be numb to your conscious sedation coding  - and what your claim should contain to stand the best chance of acceptance. First Step: Research Contracts Start your path to private-payer reimbursement by getting copies of your individual contracts with your biggest insurers.
 
"We constantly have our [doctors] asking to bill for it during procedures. But we've found that most of our payers in Wisconsin will not pay separately for it," says Margie Pfaff, corporate compliance analyst for Medical Associates Health Centers in Wisconsin, who reached this unfortunate conclusion after checking her office's contracts with major insurers.
 
For the major private companies, Curtis' office had copies of most of the contracts on file, but you can find them online or get one from the [...]