Reduce Risk of Poor Moderate Sedation Choices

Let age and time determine the codes.

By Samantha Mullins, CPC, CPC-I, ASC-AN, MCS-P
Moderate (conscious) sedation/analgesia (CPT® 99143-99150) is a drug-induced depression of consciousness during which the patient responds purposefully to verbal command, either alone or accompanied by light tactile stimulation. No interventions are necessary to maintain a patent airway—spontaneous ventilation is adequate and cardiovascular function is usually maintained—so the degree of risk is less.
Code According to Requirements
Moderate sedation codes are age and time specific. Codes 99143-99145 identify sedation provided by a physician who also performs the primary procedure.
99143                  
Moderate sedation services (other than those services described by codes 00100–01999) provided by the same physician 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; younger than 5 years of age, first 30 minutes intra-service time
99144                  
Moderate sedation services (other than those services described by codes 00100–01999) provided by the same physician 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; age 5 years or older, first 30 minutes intra-service time
+99145                  
Moderate sedation services (other than those services described by codes 00100–01999) provided by the same physician 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 intra-service time (List separately in addition to code for primary service)
A physician may choose to deliver moderate sedation for services not usually performed in the operating room (OR), but which are too invasive for the patient to tolerate with no sedation at all. An example is a simple closure of a 2 cm lip laceration on a healthy, 60-year-old patient. A physician who provides both the procedure and the moderate sedation would report 12011 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less, along with 99144 for the first 30 minutes of conscious sedation and, if necessary, one unit of 99145 for each additional 15 minutes.
When the primary physician provides moderate sedation, an independent, trained observer must be on hand to help monitor the patient. Documentation should provide proof of the observer’s presence and note that the observer monitored the patient’s cardiorespiratory functions (pulse oximetry, electrocardiogram (EKG), and respiratory monitoring and blood pressure) for the duration of the moderate sedation.
Codes 99148-99150 identify sedation provided by a physician who does not perform the primary procedure.
99148                  
Moderate sedation services (other than those services described by codes 00100-01999), provided by a physician other than the healthcare professional performing the diagnostic or therapeutic service that the sedation supports; younger than 5 years of age, first 30 minutes of intra-service time
99149                  
Moderate sedation services (other than those services described by codes 00100-01999), provided by a physician other than the healthcare professional performing the diagnostic or therapeutic service that the sedation supports; age 5 years or older, first 30 minutes intra-service time
+99150                  
Moderate sedation services (other than those services described by codes 00100-01999), provided by a physician other than the healthcare professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes intra-service time (list separately in addition to code for primary service).
For instance, consider the above example, except in this case, the patient has co-morbidities (eg, cardiac, respiratory, neurological) that put him at a higher risk and prompt the surgeon to use another physician to administer the sedation service. The surgeon would report 12011. The physician providing the moderate sedation would report 99149 and +99150, as appropriate to the time of the service.
About time: Moderate sedation codes are reported according to intra-service time, which starts with the administration of the sedation agent(s) and ends when personal contact by the sedating physician concludes. See the CPT^® manual for a list of services considered integral to moderate sedation, as well as a services that may count toward intra-service time.
Look Out for Bundled Services
CPT^® Appendix G lists codes with moderate sedation bundled (included) in the reimbursement allowed for the procedure. Codes in Appendix G also appear throughout the CPT^® manual with a “bull’s-eye” () next to them. The Centers for Medicare & Medicaid Services (CMS) instructs, “The physician can bill the conscious sedation code as long as the procedure with which it is billed is not listed in Appendix G of CPT” (see www.cms.hhs.gov/Transmittals/downloads/R1324CP.pdf).
Exceptions can occur: CPT^® allows separate reporting of 99148-99150 for moderate sedation during a “targeted” procedure, if:

1. A second physician (not the physician providing the supporting moderate sedation service) provides the moderate sedation; and
2. The moderate sedation and targeted procedure that prompts the moderate sedation occur in a facility setting.

No Anesthesiologist Required
Generally, a physician—not an anesthesiologist—administers conscious sedation. The only time an anesthesiologist should bill for moderate sedation (99143-99150) and not an anesthesia service (00100-01999) is when he is also the surgeon for the case. CMS provides the following example (see www.cms.hhs.gov/Transmittals/downloads/R1324CP.pdf):
“If the anesthesiologist or CRNA [certified registered nurse anesthetist] provides anesthesia for diagnostic or therapeutic nerve blocks or injections and a different provider performs the block or injection, then the anesthesiologist or CRNA may report the anesthesia service using CPT^® code 01991. The service must meet the criteria for monitored anesthesia care. If the anesthesiologist or CRNA provides both the anesthesia service and the block or injection, then the anesthesiologist or CRNA may report the anesthesia service using the conscious sedation code and the injection or block. However, the anesthesia service must meet the requirements for conscious sedation and if a lower level complexity anesthesia service is provided, then the conscious sedation code should not be reported.” Sedation Comes in Several Levels
Moderate sedation is just one of several sedation levels. There is also deep sedation, minimal sedation, and monitored anesthesia care (MAC).
Deep sedation/analgesia (CPT® 00100-01999) is a drug-induced depression of consciousness during which the patient cannot be easily aroused but responds purposefully following repeated or painful stimulation. Independent ventilatory function may be impaired. The patient may require assistance to maintain a patent airway. Cardiovascular function is usually maintained.
Any deeply sedated patient has a larger risk factor; sedation levels can deepen unintentionally depending on a patient’s co-morbidities, the medications administered, and the dosage and administration route. Thus only qualified anesthesia providers (anesthesiologists, CRNA, Anesthesia Assistant (AA)) should purposely induce deep sedation.
Minimal sedation (anxiolysis) is a drug-induced state during which the patient responds normally to verbal commands. Cognitive function and coordination may be impaired, but ventilatory and cardiovascular functions are unaffected. This level of anesthesia is bundled into medical procedures and not separately billable.
Monitored Anesthesia Care. Learn about MAC in the article “Draw a Line Between Moderate (Conscious) Sedation and Monitored Anesthesia Care” on page 46 in this issue.
 
Samantha S. Mullins, CPC, CPC-I, ASC-AN, MCS-P, is coding manager for DST Health Solutions in Birmingham, Ala. (http://dsthealthsolutions.com/). She has a passion for anesthesia coding with experience in pediatrics, surgery, and emergency medicine and has directed coding, compliance, billing, practice management, and managed care. Mullins has sat on the BMSC’s Anesthesia Specialty Advisory Board since 2005 and is a member of the MGMA and MGMA focus groups. She is a PMCC instructor and has served as Birmingham chapter’s 2003 president-elect and 2004 president.

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