Ensure your Oncology Documentation Leverages proper Coding for Moderate sedation

Moderate (Conscious) Sedation or MCS is the inducing of drugs to lower consciousness for any surgical procedure. However, the patient should be capable of responding to verbal direction (with or without nimble and tangible stimulation).

Starting 2017, with the changes in Medicare Physician Fee Schedule, moderate sedation will be billed and paid for using new CPT codes. Previously, sedation was billed as a part of the basic procedure. However, in oncology (especially in radiology), moderate sedation will now be reimbursed additionally (to the basic procedure). As this goes on to enhance accuracy in medical billing, it also creates new workflow requirements.

The new structure:

The changes here take into consideration the intra-service time (15 minute increments and must be aptly documented) and the patient age (under age 5, age 5 or above); and also takes into consideration if the primary physician is the same or not (the primary procedure being performed by the same or a different physician). The add-on codes refer to the addition of each 15 minute interval. It begins with the physician administering the sedation, and keeping a watch on the patient till the time the patient is stable.

Documentation requirements:

The report must comprise the patient’s age, intra-service time, and the physician’s details. Along with actual and elapsed time taken, pre and post sedation monitoring, and all pre and post services must be documented.

The changed codes:

The old codes have been eliminated (99143-99145 and 99148-99150). These codes however, are not to be used for reporting administration of medications for pain control, minimal sedation, deep sedation, or monitored anesthesia care (00100-01999).

Codes:

As per accc-cancer.org, the following changes have been implemented:

99151: Moderate sedation services provided by the same physician or other qualified health care professional 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; initial 15 minutes of intra-service time, patient younger than 5 years of age

99152: patient age 5 years or older

99153: each additional 15 minutes intra-service time (List separately in addition to code for primary service)

99155: Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intra-service time, patient younger than 5 years of age

99156: patient age 5 years or older

99157: each additional 15 minutes intra-service time (List separately in addition to code for primary service)

CMS proposes values for new moderate sedation procedure codes and wants “a uniform methodology for valuation of the procedural codes that currently include moderate sedation as an inherent part of the procedure.” Codes that include moderate sedation for radiation oncology are 77371 (stereotactic radiosurgery, multi-source Cobalt unit) and hyperthermia services (codes 77600-77615).

Further, this table from hapusa.com can be used as a guide for  the new coding structure:

Note: Code 99153 is a ‘technical-only’ code and does not include the services in a hospital, but in a practitioner’s office setting only.

The new changes in 2017 in codes, rules and regulations will certainly bring about challenges and apprehensions in oncology billing and coding. But ensuring compliances and guidelines by oncology coders will make it relatively easier for accurate and timely reimbursements.