Pediatric Moderate (Conscious) Sedation
Effective January 1, 2006, Procedure codes 99141 and 99142 were deleted and have been replaced with Procedure codes 99143 (Moderate sedation services…provided by the same physician performing the diagnostic or therapeutic service…requiring the presence of an independent trained observer to assist in the monitoring of the patient’s…under 5 years of age, first 30 minutes intra-service time), 99144 (…age 5 years or older, first 30 minutes intra-service time), and add-on code 99145 (…each additional 15 minutes intra-service time).
• Claims for moderate sedation should be submitted hard copy indicating the medical necessity for the procedure. Documentation should also reflect pre- and post-sedation clinical evaluation of the patient.
• Moderate sedation does not include minimal sedation (anxiolysis), deep sedation or monitored anesthesia care (00100-01999).
• Moderate sedation is restricted to recipients from birth to age 13. (Exceptions to the age restriction will be made for children who are severely developmentally disableddocumentation attached must support this condition. No claims will be considered for recipients twenty-one years of age or older)
• Moderate sedation includes the following services (which are not to be reported/billed separately):
* * Assessment of the patient (not included in intraservice time);
* * Establishment of IV access and fluids to maintain patency, when performed;
* * Administration of agent(s);
* * Maintenance of sedation;
* * Monitoring of oxygen saturation, heart rate and blood pressure; and
* * Recovery (not included in intraservice time)
• Intraservice time starts with the administration of the sedation agent(s), requires continuous face-to-face attendance, and ends at the conclusion of personal contact by the physician providing the sedation.
• Louisiana Medicaid has adopted Procedure guidelines for procedures that include moderate sedation as an inherent part of providing the procedure. Louisiana Medicaid does not reimburse when a second physician other than the health care professional performing the diagnostic or therapeutic service provides the sedation. Claims paid inappropriately are subject to recoupment.
Additional Anesthesia Information
• CRNAs must place the name of their supervising doctor in Item 17 of the CMS 1500 or 837P claim form.
• Anesthesia time begins when the provider begins to prepare the patient for induction and ends with the termination of the administration of anesthesia.
• Time spent in pre- or postoperative care may not be included in the total anesthesia time.
• A surgeon who performs a surgical procedure will not also be reimbursed for the administration of anesthesia for the procedure.
• A group practice frequently includes anesthesiologists and/or CRNA providers. One member may provide the pre-anesthesia examination/evaluation, and another may fulfill other criteria. The medical record must indicate the services provided and must identify the provider who rendered the service. A single claim must be submitted showing one member as the performing provider for all services rendered. In other words, the billing of these services separately will not be reimbursed.
• Anesthesia for arteriograms, cardiac catheterizations, CT scans, angioplasties and/or MRIs should be billed with the appropriate code from the Radiological Procedures subheading in the Anesthesia section of Procedure .
• Procedure code 00952 (Anesthesia for vaginal procedures…; hysteroscopy and/or hysterosalpingography) pends to Medical Review and must be submitted hardcopy with the anesthesia record attached.
When billed for anesthesia administered during a hysterosalpingogram, Procedure code 58340, the documentation attached must indicate:
* * medical necessity for anesthesia (diagnosis of mental retardation, hysteria, and/or musculoskeletal deformities
that would cause procedural difficulty) and
* * that the hysterosalpingogram (HSG) meets the criteria for that procedure (see the Medical Review section-Billing
Information)
• Anesthesia for dental restoration should be billed under Procedure anesthesia code 00170 with the appropriate modifier, minutes and most specific diagnosis code. Reimbursement is formula-based, with no additional payment being made for a biopsy. A provider does not have to perform a biopsy to bill this code.
• Anesthesia for multiple surgical procedures in the same anesthesia session must be billed on one claim line using the most appropriate anesthesia code with the total anesthesia time spent reported in Item 24G on the claim form.
The only secondary procedures that are not to be billed in this manner are tubal ligations and hysterectomies.
• Anesthesia claims with a total anesthesia time less than 10 minutes or greater than 224 minutes must be submitted hard copy with the appropriate anesthesia graph attached.
• Anesthesia claims for multiple but separate operative services performed on the same recipient on the same date of service must be submitted hard copy, with a cover letter indicating the above. The anesthesia graphs from the surgical procedures should be included and the claim with attachments should be submitted to Unisys at the address below.
• When anesthesia claims deny with error codes 749 (delivery billed after hysterectomy was done) or 917 (lifetime limits for this service have been exceeded), a new claim must be submitted to Unisys at the address below with a cover letter describing the situation.
