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Moderate (Conscious) Sedation Coding Guidelines

Moderate Sedation Coding Guidelines

To ensure accurate billing, it’s essential to follow Sedation Coding Guidelines, which specify the proper codes for different sedation levels and procedures. By adhering to these challenges, medical practices can avoid coding errors and ensure appropriate reimbursement.

Moderate sedation is a service provided by the physician or other qualified healthcare professional performing the diagnostic or therapeutic service that the sedation supports. It requires the presence of an independent trained observer to assist in monitoring the patient’s level of consciousness and physiological status.

The codes to report moderate sedation include all three components: pre-service, intra-service, and post-service.  However, the intra-service work drives the selection of codes by time.  Below is a summary of what constitutes each component as defined by CPT.

Pre-Service Work

The following pre-service work components are not included when determining the intra-service time:

  • Assessment of past medical and surgical history with an emphasis on cardiovascular, pulmonary, airway, or neurological conditions;
  • Review of the patient’s previous experiences with anesthesia and/or sedation and family history of sedation complications;
  • Summary of the patient’s present medication list;
  • Drug allergy and intolerance history;
  • Focused physical exam with emphasis on mouth, jaw, oropharynx, neck, and airway for Mallampati score assessment; chest and lungs; and heart and circulation
  • Vital signs, including heart rate, respiratory rate, blood pressure, and oxygenation with end-tidal CO2 when indicated;
  • Review of any pre-sedation diagnostic tests;
  • Completion of a pre-sedation assessment form;
  • Patient informed consent;
  • Immediate pre-sedation assessment before first sedating doses and
  • IV access and fluids.

Intra-Service Work

Because it is the intra-service time (only) that is used to determine the appropriate moderate sedation CPT code(s), you must be aware of how CPT defines it:

  • Begins with the administration of the sedating agent(s);
  • Ends when the procedure is completed, the patient is stable in recovery status, and the physician or other qualified health care professional providing the sedation ends personal continuous face-to-face time with the patient;
  • Includes ordering and/or administering the initial and subsequent doses of sedating agents;
  • Requires continuous face-to-face attendance by the physician or another qualified healthcare professional
  • Requires monitoring of patient response to the sedating agents;

If you are performing the procedure, you will be required to supervise and direct an independent trained observer who will assist in monitoring the patient’s level of consciousness and physiological status throughout the procedure.

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Following Sedation Coding Guidelines is crucial for accurate billing and compliance in medical practices. These guidelines help define the correct codes for varying levels of sedation, ranging from minimal to deep sedation. Coders who adhere to Sedation Coding Guidelines reduce the risk of claim denials and audits due to incorrect coding or documentation. This can help ensure medical facilities receive proper reimbursement for their sedation services.

Medical Billers and Coders, a leading medical billing company, understands the importance of Sedation Coding Guidelines and has a team of experts dedicated to applying them correctly. By following Sedation Coding Guidelines, MBC ensures that the billing process is smooth and efficient, allowing healthcare providers to focus on patient care. When practices use the correct codes outlined in Sedation Coding Guidelines, they can avoid costly billing mistakes and streamline their revenue cycle management.

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Post-Service Work

Once the continuous face-to-face time ends, additional face-to-face time cannot be added to the intra-service time. However, it is part of the post-service work.

The following post-service work components are not included when determining the intra-service time for reporting:

  • Assessment of the patient’s vital signs, level of consciousness, neurological, cardiovascular, and pulmonary stability in the post-sedation recovery period;
  • Evaluation of the patient’s readiness for discharge;
  • Preparation of the documentation;
  • Communication with the family/caregiver regarding the sedation

Documentation

  • The intra-service time is the only time that can be counted to determine the assignment of the CPT code(s);
  • CPT has defined the intra-service time as “It begins with the administration of the sedation agent(s), requires continuous face-to-face attendance, and ends when the personal face-to-face time ends with the patient;
  • It would be best if you used language that mirrors CPT terminology; other terms used, such as “total time spent was…’ or “encounter time was…’ cannot be counted;
  • The pre-sedation and post-sedation work is required; none of this time can be calculated to determine code selection;
  • Because having a trained independent observer is required to be sure to include this information in your documentation;
  • Do not include any of the pre-service and post-service work when calculating the intra-service time

CPT Codes

Codes for moderate sedation are chosen and assigned based on three primary factors:

  • Whether the same provider is both administering the sedation and performing the procedure for which the sedation is required. Coding changes when a different provider administers the sedation. For example, a patient undergoes a method that requires moderate sedation. The treating physician will perform both the supported procedure and the moderate sedation service. The physician will supervise and direct an independent, trained observer who will assist in monitoring the patient’s level of consciousness and physiologic status throughout the procedure. If a different provider, other than the provider performing the primary method, administers moderate sedation, an independent observer is not required.
  • Whether the patient is younger than five years of age, five years old, or older.
  • The procedure’s ‘intra-service time’ begins with administering the sedation agent and ends when the procedure is completed, the patient is stable in recovery status, and the provider performing the sedation ends personal continuous face-to-face time with the patient.

Total Intra-service Time

Patient age

CPT Code(s)=Same physician performing procedure

CPT Code(s)=Different physician who is performing a procedure

Less than 10 minutes Any Age Not reported separately Not reported separately
10-22 minutes  < 5 years 99151 99155
10-22 minutes Five years or older 99152 99156
23-37 minutes < 5 years 99151 + 99153 x1 99155 + 99157 x1
23-37 minutes Five years or older 99152 + 99153 x1 99156 + 99157 x1
38-52 minutes < 5 years 99151 + 99153 x2 99155 + 99157 x2
38-52 minutes Five years or older 99152 + 99153 x2 99156 + 99157 x2
53-67 minutes < 5 years 99151 + 99153 x3 99155 + 99157 x3
53-67 minutes Five years or older 99152 + 99153 x3 99156 + 99157 x3
68-82 minutes < 5 years 99151 + 99153 x4 99155 + 99157 x4
68-82 minutes Five years or older 99152 + 99153 x4 99156 + 99157 x4

 

CPT CODE

DESCRIPTION

MODERATE SEDATION PERFORMED BY THE SAME PROVIDER
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 five years of age
99152 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 age five years or older
99153 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; each additional 15 minutes of intra-service time
MODERATE SEDATION PERFORMED BY ANOTHER PROVIDER
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 five years of age
99156 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 age five years or older
99157 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; each additional 15 minutes of intra-service time

Update:

The Centers for Medicare & Medicaid Services (CMS) determined that the moderate sedation work for particular gastrointestinal (GI) endoscopy procedures differs from other endoscopy procedures. You should report G0500 instead of 99151-99152 when reporting moderate sedation to Medicare patients in addition to designated GI endoscopy services. You can find a list of designated GI endoscopy codes here. When reporting G0500, you may report additional time beyond the initial 15 minutes of intra-service time using 99153.

FAQs

  • What is moderate (conscious) sedation?

Moderate sedation, or conscious sedation, is when the patient remains conscious and responsive but is relaxed and free from pain during medical procedures.

  • What are the 4 levels of sedation?

    1. Minimal Sedation: Patients are relaxed but fully awake and responsive. They can maintain their own airway and communicate effectively.
    2. Moderate Sedation: Patients are drowsy but can respond to verbal commands or light stimulation. Airway maintenance is usually not a concern.
    3. Deep Sedation: Patients are not easily arousable and may need assistance with airway maintenance. They might not respond to verbal commands but can be roused with repeated stimulation.
    4. General Anesthesia: Patients are completely unconscious and unresponsive. Airway support and controlled ventilation are required.
  • What are the critical coding guidelines for moderate (conscious) sedation?

The coding guidelines for moderate sedation typically include specific CPT (Current Procedural Terminology) codes that indicate the level of sedation, duration, and who administers it (physician or other healthcare professional). Using the correct codes is essential to ensure accurate billing.

  • When is it appropriate to use moderate sedation codes?

Moderate sedation codes are used when sedation is administered to a patient during a procedure, such as minor surgeries or diagnostic tests, where the patient needs to be relaxed but not entirely unconscious.

  • What documentation is required to support moderate sedation coding?

Documentation should include details of the sedation procedure, such as the dosage and type of sedation used, the duration, the medical staff involved, and the patient’s response during and after the procedure. Accurate documentation is critical to billing correctly and avoiding claim denials.

  • How can Medical Billers and Coders help with moderate sedation coding?

Medical Billers and Coders (MBC) specializes in Medical Billing and Coding, including moderate sedation. MBC’s experts ensure compliance with guidelines and help healthcare providers avoid billing errors, reducing the risk of audits and claim rejections. They can also assist with training and best practices in sedation coding.

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