Pediatric Coding Alert

Question: Insurance companies deny conscious sedation claims based on the fact that a pediatrician, not an anesthesiologist, performs the procedure and sedation. According to CPT, "The use of these codes requires the presence of an independent trained observer to assist the physician in monitoring the patient's level of consciousness and physiological status." When our hospital pediatricians perform these sedations, a nurse and the physician are present at all times. Would you clarify who may use conscious sedation codes and what route I should take with these claims?

New Jersey Subscriber
 
Answer: CPT doesn't restrict conscious sedation codes (99141, Sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation; 99142, ... oral, rectal and/or intranasal) to anesthesiologists. As long as the same physician who performs the procedure administers the sedation and an independent trained observer is present to assist the physician, any doctor may use 99141-99142, according to CPT Assistant, July 1998.

Since your pediatrician has met the criteria for 99141-99142, you should appeal these denials. Include a copy of CPT Assistant and a letter explaining the extenuating circumstances that made conscious sedation necessary. You should copy the supporting documentation to the claim with a quick note on the CMS-1500 saying, "See attached documentation."

For instance, your pediatrician attempts to close a small child's 2.6-cm cheek wound (12013*, Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm). The child moves continuously, making suturing difficult and risky. So, the pediatrician administers 10 mg of propofol intravenously (99141) to sedate the child.

Encourage your pediatrician to include a note stating why the child needed sedation for a procedure that most adults could tolerate without analgesia as well as the increased work of the additional monitoring of the independent trained observer. The added explanation could get your claims paid. In the future, you should include a copy of CPT Assistant's conscious sedation criteria, a cover letter, and documentation with 99141-99142 claims.