What is Moderate Sedation?
Moderate sedation is also known as conscious sedation. This is a sedation medication used during procedures to help patient feel relaxed and follow directions while awake and still feel no pain or anxieties. Most patients state they have no memory of the procedure despite being awake the entire time. A patient’s blood pressure, heart rate and breathing should be monitored during the procedure.
Quick Reference
Moderate sedation performed by provider performing surgical/therapeutic/diagnostic service
99151- First 15 minutes of sedation for a patient younger than 5 years of age performed by the physician or other qualified health care professional rendering the care that supports the sedation.
99152- First 15 minutes of sedation for a patient 5 years of age or older performed by the physician or other qualified health care professional rendering the care that supports the sedation.
99153- Each additional 15 minutes of sedation for either 99151 or 99152
Quick Reference
Moderate sedation provided by a qualified healthcare profession OTHER THAN the provider performing surgical/therapeutic/diagnostic service
99155- First 15 minutes of sedation for a patient younger than 5 years of age performed by the physician or other qualified health care professional rendering the care that supports the sedation.
99156- First 15 minutes of sedation for a patient 5 years of age or older performed by the physician or other qualified health care professional rendering the care that supports the sedation.
99157- Each additional 15 minutes of sedation for either 99151 or 99152
Is the provider getting all the necessary documentation completed?
Moderate sedation codes 99151-99157 can be reported when the following documentation is complete:
· Previous patient anesthesia history must be reviewed by the provider along with family history of sedation complications.
· History- past medical, surgical & drug allergies.
· Exam- a focused exam documenting chest, lungs, heart, circulation, mouth, jaw, neck and airway were examined.
· Documentation supporting the physician reviewed pre-sedation diagnostic testing.
· Pre-sedation assessment form completed along with patient consent form.
· Documentation of IV access and fluids given to patient.
· Start time is documented and reflects the time in which the physician is present along with an end time which is when the physician leaves the room.
· Document the use of a trained independent observer.
· When all the above listed documentation has been confirmed and documented prior to the sedation you can select the most appropriate CPT.
Let’s Talk Negatives
· Physicians will not be reimbursed by Medicare for CPT code 99153 when done in a facility/hospital setting. CMS designed 99153 as a technical component only code for physician billing.
· If less than 10 minutes of sedation is performed do not report any moderate sedation codes.
· You may not report the required exams, monitoring or time spent documenting the pre-service, intra-service or post service work (assessment of the patient, consent, record review, monitoring vitals, discharge, pulse oximetry, etc).
· Do not report moderate sedation with minor sedation (anxiolysis).
QUESTIONS ASKED WILL BE ANSWERED
Q: What is considered and independent trained observer?
A: CPT guidelines state than an independent trained observer is an individual who is qualified to monitor the patient during the procedure, who has no other duties during the procedure. Make sure the provider documents the observers name and credentials.
Q: How do I calculate the time for moderate sedation?
A: Start time begins when the physician is present, and the sedation is administered. The time ends when the physician is no longer required to have face to face time with the patient. AKA- patient is stable enough to move to recovery.
Q: Does the doctor have to reach the full 15 minutes to bill the next additional 15 minutes of sedation?
A: No, at least 8 additional minutes of sedation must have occurred after achieving the previous 15-minute block of time.
Contact Us
Sloan Medical LLC
Revenue Cycle Management for Vascular and General Surgery
Overland Park KS
66213
913-634-3837
alex.nedzelskiy@sloanmed.com
WWW.Sloanmed.com
Comments