Proper Coding and Documentation for Moderate Sedation

Proper Coding and Documentation for Moderate Sedation

Moderate sedation (99143-99150) is a drug-induced depression of consciousness. No interventions are necessary to maintain a patent airway, and cardiovascular function is usually maintained. The patient is sedated, but can respond purposefully to verbal command.

Moderate sedation codes are (patient) 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 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; 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 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; 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 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 intra-service time (List separately in addition to code for primary service)

When the primary physician provides moderate sedation (as described by 99143-99145), 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 during 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 or other qualified health care professional other than the health care professional performing the diagnostic or therapeutic service that the sedation supports; younger than 5 years of age, first 30 minutes intra-service time

99149 Moderate sedation services (other than those services described by codes 00100-01999), provided by a physician or other qualified health care professional other than the health care 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 or other qualified health care professional other than the health care 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)

Report 99143-99150 by “intra-service” time. Intra service time starts with the administration of the sedation agent(s) and ends at the conclusion of personal contact by the physician providing the sedation.

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” (ʘ) next to them. The Centers for Medicare & Medicaid Services (CMS) transmittal R1324 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.”

2017-code-book-bundles-728x90-01

John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 404 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

Leave a Reply

Your email address will not be published. Required fields are marked *