General Surgery Coding Alert

Question: A patient with severe upper abdominal pain reported to the office for an endoscopy. The surgeon induced conscious sedation with a 25-milligram injection of Demerol, inserted the endoscope and biopsied the patient's gastric mucosa. How should I code this visit?

Arkansas Subscriber

Answer: The correct answer depends on whether your insurer is a Medicare or a private payer.

Medicare: If you are filing this claim with Medicare, report 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple) linked with 789.0x (Abdominal pain) for the endoscopy. Medicare payment for endoscopic services performed in the office setting includes an additional payment (site-of-service differential) to cover the cost of the equipment, disposable supplies, and medication.

You cannot report the conscious sedation separately if you're filing with Medicare carriers. Medicare bundles conscious sedation to endoscopy codes. However, for the sake of good record-keeping, document the conscious sedation on the patient's file and enter it into the office computer system with a zero-dollar amount. If you use this method, your office can track conscious sedations, but they won't be reported to the insurance company.

Private payer: If you are filing this claim with a private carrier, you should report the conscious sedation, because some insurers will reimburse for the service. Report 43239 first, then 99141 (Sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation). Use the same ICD-9 code (789.0x) for 43239 and 99141, and report J2175 for the Demerol.

Not all carriers will pay for conscious sedation. Your ability to be reimbursed for the conscious-sedation service will depend on your commercial carrier's policy and, if applicable, your contract with that carrier. If you don't know the individual insurer's policy on conscious sedation, call the insurer and ask if it will reimburse for conscious sedation.