Pediatric Coding Alert

Although many pediatric practices receive denials for conscious sedation, this six-point checklist will improve your bottom line. 1.Code to Reflect Administration Select a conscious sedation code based on how the drug was administered. When a drug is given intravenously, use 99141 (Sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation). For oral administration, report 99142 ( oral, rectal and/or intranasal). For instance, suppose a patient who has minor facial lacerations presents to a pediatrician's office. Due to the location of the injury, the child moves continuously, making suturing difficult and risky. So, the pediatrician administers 10 mg of propofol intravenously to sedate the child.

For the laceration repair, report 12013* (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm). The pediatrician adds the three lacerations together. Each laceration is from the same anatomic site (face) and classification (simple). Therefore, CPT guidelines allow reporting the "sum of lengths of repairs for each group of anatomic sites." The wounds are 1 cm, 1.5 cm and 2 cm. The total is 4.5 cm, making 12013* correct. For the conscious sedation, report 99141. The physician administered the sedative intravenously. Therefore, 99141 accurately describes the administrative technique. If the pediatrician performs an office visit to assess the child's wounds and any additional injuries, such as head trauma, you should report an office visit (99201-99205, New patient office visit; 99211-99215, Established patient office visit) in addition to the laceration repair. Append the office visit with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to indicate a separate E/M service. 2. Meet Performance Criteria "Conscious sedation codes are very specific," says Lisa M. Bride, paralegal, Pediatric Management Consultants, Manhattan Beach, Calif. "They are used only when the physician does both the sedation and the procedure."

Therefore, the previous laceration scenario qualifies for conscious sedation codes; the pediatrician administered the propofol and repaired the laceration. In a contrasting scenario, suppose a pediatric patient who has developmental delays and emotional problems, including claustrophobia and fear of needles, is scheduled for an MRI. The radiologist performs the MRI, and the pediatrician administers ketimine orally. The pediatrician should bill the appropriate anesthesia code from the 00100-01999 series, and the radiologist would bill for the MRI only. The pediatrician cannot report conscious sedation, because he has not met the performance qualifications. Similarly, the radiologist cannot report the conscious sedation because she did not administer the drugs. The pediatrician bills 01922 (Anesthesia for non-invasive imaging or radiation therapy) "with modifier -52 (Reduced services) to reduce the fee because the [...]