Appendix G


Las Vegas, Nevada
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:confused: I need some quick help if anyone can offer it...

My doctors provide sedation services for pediatric patients in the hospital setting. We typically bill Anesthesia codes for our services, but there is confusion among my doctors about Conscious Sedation vs. Deep Sedation.

The question Appendix G there is a list of codes that include Conscious Sedation. The interpretation of the guidelines is causing much confusion.

This passage: "Moderate sedation does not include minimal sedation (anxiolysis), deep sedation, or monitored anesthesia care (00100-01999)."
sounds to me as if because we are billing monitored anesthesia care/deep sedation, it is possible for our physicians to bill for a code included in Appendix G AND the associated anesthesia services.

For example:
Insertion of a PICC line 36568 billed with 47 modifier and then in addition billing the 00532 for the anesthesia as well.

So I am reading this as regardless of the fact that the PICC line may be on the conscious sedation list, because we bill for monitored anesthesia services, we are still able to bill for both. (I hope I'm making sense here. The more I over analyze the phrasing the more it's confusing me and therefore I can't explain it coherently to my boss.)

Am I reading this correctly? :confused:

Thanks in advance. :)
You can use Monitored Anesthesia care for those CPT codes in Appendix G under certain circumstances.

For example:

- the provider of anesthesia services has to be different than the surgeon.
- the type of anesthesia must be either MAC (monitored anesthesia care) or GA

- For many carriers, there must be some kind of reason that justifies the need for anesthesia services (provided by another MD/CRNA). This reason is usually in the form of some kind of co-morbid condition that makes doing the procedure unsafe or harmful for the patient to go through under "ordinary circumstances".

As you well know, you aren't going to get a 2-year old baby to stay still long enough to insert a PICC line - you need them sedated - deeply! and again, as you well know, you need to have an independent trained observer because of the depth of sedation required. But like you said, how deep is "deep"?

I use this table here to educate the others about the levels of sedation & the codes that go with them:

The the first column, minimal sedation is more than likely not billable or inclusive with the procedure - like giving a patient a valium or benedryl to make them sleepy but they're still "there"; the 2nd column is more like the 9914x series of codes; last two columns on the left are where you'd use anesthesia codes - deep sedation/GA;

Re: Your example:
Insertion of a PICC line 36568 billed with 47 modifier and then in addition billing the 00532 for the anesthesia as well.

If/when you bill that way, you're telling the insurance companies this scenario:

The surgeon who is inserting the PICC is giving anesthesia/sedation to the patient (36568-47 - billed by the surgeon), a CRNA or anesthesiologist is also providing anesthesia services for the surgeon (00532 - billed by the CRNA or Anesthesiologist). This will never happen UNLESS the surgeon's anesthesia/sedation didn't take and a CRNA or anesthesiologist was called in to provide something deeper.

A surgeon will never bill using anesthesiology codes, either. They are strictly CPT/HCPCS. However, it's possible for an anesthesiologist to use both the CPT and Anesthesia codes (that's another LONG story).

So, in direct answer to your question (don't you wish this was just oh, so simple?): YES, for CPT codes in Appendix G, anesthesia services by an anesthesiologist/CRNA can be given to a patient, yes they can be billed & yes, you can get paid for them - IF those conditons apply and IF you code/bill them out correctly.

Leslie Johnson, CPC
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I too, have almost the SAME situation

In trying to clarify with the physician's who are providing the anesthesia, they had previously been billed as "conscious sedation". In communicating on my own with the providers, I find out that the physician's classification is "deep sedation".

How should this be billed.......if performed alone?

How should this be billed..........if performed with or without the procedures listed in Appendix G?

I SO needing assistance in this area. PLEASE, PLEASE help me here. I want this done ACCURATELY.

Am I missing something? There were numerous anesthesias that had been reported as "unlisted" and I'm thinking that I need to go back to the providers and clarify with them, providing them with more information and CPT's on this subject.

Thank you so much in advance.
Anesthesia VS. Sedation?

Let me do I find the complete description of the "content" of the anesthesia? I'm not certain I am asking the right question. But let me give an example.

For instance, the CPT codes have a CPT assistant that actually gives in "laymens" terms the description of what the code means like 99148-99150.

The 00635 anesthesia code does not.

There are times the providers report "sedation". When they do this.....they actually mean "deep sedation/analgesia". I understand that anesthesia billing is reported by time, but what resources are out there and can someone help explain to me the difference between and when the 2 should be differentiated?
picc-line insertion in an office setting

Hello All,

Our practice is looking into doing picc-line insertion in an office setting which is completely new to us. I need help as to what exactly is billable and payable performed by a nurse practiononer. CPT code for picc insetion is 36569. What about ultrasound and fluoroscopically guided and local anesthesia? Are all the procedures mentioned above even able to be performed by a nurse practitioner and in an office setting? Any guidance is much appreciated....

Jeanie P
Optimal MD Solutions