These expert tips will help you be alert and aware of when to report conscious sedation (or anesthesia) in an emergency department (ED).
You should report the CPT code for anesthesia to your physician when he administers conscious sedation to another doctor who is performing the surgery. Ask your physician to provide a copy of the flowsheet. It will contain all information about the medication the physician gave the patient, the updates of vital-signs and the number times he performed each one.
Remember to determine the appropriate anesthesia base unit for the procedure before you add the time units. Below is a quick three-step guide to help you correctly and accurately report anesthesia services.
1. The CPT code lookup will give you a variety of options. You may need to report more than one CPT Code. However, you should only take the CPT dominant code. This code is the one that represents the surgery that your doctor performed. Based on that code, you will determine the appropriate anesthesia codes from the section 000100-01999.
2. ASA guidelines further determine the base units that are to be assigned to this particular anesthesia code.
3. Add time units to your record, based upon the increments made by your payer.
Additionally, it may be necessary to use one of these patient status modifiers when reporting anesthesia codes. You can ask your physician for documentation of the patient's condition so that you know which modifier to apply
• P1 - Normal healthy patient
• P2 – Patient with mild systemic diseases
• P3 – Patient with severe systemic illness
• P4 – Patient with severe, systemic disease that poses a constant threat for life
• P5 – Moribund patient that is not expected survives without the operation
• P6 – Declared brain-dead person whose organs are being taken for donor purposes
Note: These modifications are only applicable to the anesthesia codes, and not to conscious code. When reporting conscious sedations codes, please remember these guidelines:
1. Conscious sedations codes may be reported along with any other CPT code.
2. Pulse oximetry should be reported in conjunction with conscious sedation codes.
3. It is not a good idea to report conscious sedations with anesthesia.
4. Conscious sedations codes require that a trained observer be present during the procedure. You can check your documentation to see if anyone was there.
5. Morphine and demerol, when used in isolation, don't usually constitute conscious. However the physician might use them alongside higher-level drugs such as midazolam, ketamine, or ketamine.
6. Codes whose descriptions contain words like "with" and "without" anesthesia should be reported "without anesthesia" during conscious sedation procedures.
7. The modifier -47 (Anesthesia performed by a surgeon) must be used when reporting any sedation codes.
