Medicare makes moderate sedation payable

Should your primary care physicians ever find cause to perform moderate sedation, you’ll be interested in a new Medicare policy that may make it payable as of Oct. 1. Medicare Pub. 100-04 Transmittal 1324 finally makes Medicare policy consistent with the fee schedule pricing for codes 99143-99150. It allows your carrier to pay for moderate sedation when it’s performed by the same physician who does the procedure (codes 99143-99145).

A little history: The Medicare fee schedule has carrier-priced moderate sedation codes 99143-99150 ever since their inception in the 2006 CPT manual. However, that fact has not been reflected in the Medicare Claims Processing Manual, Pub. 100-04, Chapter 12, Section 50 (A), which up until now has stated only:

“Carriers may not allow separate payment for the anesthesia service performed by the physician who also furnishes the medical or surgical service. In that case, payment for the anesthesia service is made through the payment for the medical or surgical service.”

Because of the way the Medicare manual was written, carriers didn’t feel they had to process claims for moderate sedation performed by the surgeon – and many practices weren’t coding it because they weren’t sure they could, explains coding consultant Marvel Hammer, MJH Consulting, Denver, Colo. “I think it left a big gray window for carriers to do whatever they wanted,” she says.

Now the Claims Processing Manual clarifies Medicare policy to say that a physician who performs moderate sedation in conjunction with a procedure can bill both services, as long as the procedure isn’t listed in CPT manual Appendix G. According to Medicare Pub. 100-04 Transmittal 1324, brand-new manual Chapter 12, section 50 (L):

“CPT codes 99143 to 99145 describe moderate sedation provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status. The physician can bill the conscious sedation codes 99143 to 99145 as long as the procedure with (which) it is billed is not listed in Appendix G of CPT.”

Its great news, says Hammer. “It’s just a very black-and-white clarification from the CMS national office that moderate sedation is not included in the global surgical package,” she says. “CMS is saying, ‘They’re payable services. We’re just leaving it up to the carriers to determine payment,’” she adds.

Resources:

For more details, view Transmittal 1324 at www.cms.hhs.gov/transmittals/downloads/R1324CP.pdf

View the Claims Processing Manual at www.cms.hhs.gov/manuals/downloads/clm104c12.pdf