Moderate Sedation Bundles, No More

Moderate Sedation Bundles, No More

Changes in the Medicare Physician Fee Schedule 2017 Final Rule and CPT® 2017 mean that moderate sedation is no longer bundled, under any circumstances.

As noted in the 2015 Physician Fee Schedule Proposed Rule, many codes valued to include moderate sedation were reported instead with a separate, associated anesthesia code (as allowed by CPT® guidelines). In other words, rather than administer moderate sedation (which was included in—and paid for as part of—the primary procedure), providers performed a separately reimbursable anesthesia service.

For 2017, those codes that, in previous years, were valued to include moderate sedation (when performed) are revalued to no longer include moderate sedation. Although the value of those codes has fallen, moderate sedation, when performed and properly documented, now may be reported separately. Per the 2017 Physician Fee Schedule Final Rule, “This coding change [provides] for payment for moderate sedation services only in cases where it is furnished.”

Both CPT® Appendix G, which previously listed all codes that included moderate sedation, and the “bulls eye” symbol, which previously indicated that the specified code included moderate sedation, are removed from CPT® 2017. A total of 441 (mostly endoscopic) CPT® codes no longer include moderate sedation, with no further changes to the code descriptors. Two codes (92978 and 92979, which describe endoluminal imaging of coronary vessel or graft) no longer bundle moderate sedation, but also include additional descriptor changes.

Prior codes to describe moderate sedation (99143-99150) are deleted and replaced by new, time-based codes that distinguish whether the same provider, or a different provider, performs both the primary procedure the moderate sedation; and, patient age.

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 intraservice time, patient younger than 5 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 intraservice time, patient age 5 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 intraservice 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 intraservice time, patient younger than 5 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 intraservice time, patient age 5 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 intraservice time (List separately in addition to code for primary service)

CMS stipulates in the 2017 Physician Fee Schedule Final Rule that the moderate sedation work for certain esophageal dilation, biliary endoscopy, and endoscopic retrograde cholangiopancreatography (ERCP) procedures differs from that of other endoscopy procedures. For this reason, CMS augments the new moderate sedation CPT® codes, above, with a gastro-intestinal (GI) endoscopy-specific moderate sedation code, G0500 Moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that 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 5 years or older, to be applied instead of CPT® 99151-99152 when reporting moderate sedation to Medicare patients in addition specified GI endoscopy services.

When reporting G0500 to Medicare, additional time beyond the initial 15 minutes of intraservice time may be reported using 99153, as appropriate.

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

Latest posts by John Verhovshek (see all)

About Has 442 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.

6 Responses to “Moderate Sedation Bundles, No More”

  1. Karen says:

    We are reading conflicting articles on these new codes and are still trying to get solid answers regarding this subject.

    If our Dr. performs a day’s worth of GI procedures but has another physician providing anesthesia, do we report any of these new codes, other than the procedure code?

    On the days where Dr. providers conscious sedation himself, we report the codes along with the CPT for the procedure, however, should there be a fee attached to the new codes since it appears that the CPT no longer includes conscious sedation?

  2. Debra says:

    I checked the Medicare Fee Schedule for G0500. For our area they’re allowing $5.44 for G0500 & $10.45 per unit of 99153. So we will be adding the charge.

  3. Barbara White says:

    Does the physician need to document the supervision of moderate sedation in his report or is the hospital documentation (for example, cath lab flow sheet) sufficient for him to bill his service, if it contains all of the detail?

  4. Myka Jens, CPC says:

    Medicare’s MUE states 9 units for 99153. What do we bill if the sedation time goes over that?

  5. Terrance Jenkins says:

    Does 99152 and 99153 apply when the Dr. does both the procedure and the sedation? We have some 99153 being denied even when the info is documented that an RN was there and the time. How would you solve this problem?

  6. Vaidyanathan M says:

    HI,

    Can anyone explain me, CPT 99153 required any modifier. Because recently I got denial Add on CPT 99153 for Moderate sedation need to add modifier. I have called & checked with Medicare, explained him that the primary procedure G0500 was paid & add on code was denied. But still he stated that the modifier is needed as per the POS. Our POS is 24 Ambulatory & CPT 99153 is related to professional component. Please review & advice.

Leave a Reply

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