We are having difficulty getting paid for conscious sedation when reporting this with our fracture codes in the ER. Is 99141 the correct code and should we be getting reimbursed?

The CPT codes for fracture manipulation in the ER do not include the services associated with the orthopaedic physician administering the anesthetic agent (IV conscious sedation). The surgical package definition states that local anesthetics and digital blocks are included, but regional anesthetic and IV conscious sedation when administered by the surgeon may be reported separately.

So, while this is correct coding per the AMA CPT coding rules, here’s the dilemma and reason for the denials. Medicare states that any anesthesia by the operating surgeon is included in the surgical package, and will not reimburse the surgeon for any type of anesthesia during the same operative session. As such, CPT code 99141 will be denied by Medicare as inclusive in the fracture or surgical CPT code.

Let’s take a look at this for your private payors and ask the following questions.

1. Do you have documentation from the private payor stating they follow Medicare’s rules as it relates to the surgical package and administration of regional blocks or anesthesia? If yes, then write it off as a payor disallowed service.
2. If you do not have such documentation then we have to continue with the questions. If the answer is no….
3. Do you have documentation from the physician that he or she administered the drug, i.e. the physician pushed the drug and not the nurse who is employed by the hospital? If the physician administered and documented the service and someone from the hospital monitored the patients vital signs, pulse oximetry and EKG, we will submit the service and appeal the denial.
4. If the answer is no, write the service off to a coding error adjustment as 99141 should not have been reported separately.

The documentation supports the work, the payors have not communicated in writing that conscious sedation is not separately reportable, how do I appeal?

1. Copy the notes showing the physician performed and documented the service as billed.
2. Copy the codes in the 2005 CPT Appendix where the AMA and societies have indicated conscious sedation is included in the procedure, thus it cannot be reported separately. Note in the letter that none of the new codes include the fracture codes or the surgical procedure you are reporting.
3. Indicate to the payor, that the physician incurred the risk of performing the service in the ER to avoid taking the patient to the OR and incurring unnecessary costs and emotional stress. Indicate that the cost of reimbursing for conscious sedation (1.23 RVUs in 2005) is significantly less than the cost the payor would have to incur if the patient was taken to the OR for reduction under MAC anesthesia.
4. Copy the patient on the appeal letter. If the payor decides to reimburse, the patient may have responsibility for some portion of the service. You will want the patient to know why they may receive an additional bill if they have a co-responsibility for the service.

Mary LeGrand, RN, MA, CCS-P
KarenZupko & Associates, Inc.