Moderate Sedation Coding

Moderate Sedation Coding

Moderate sedation, also sometimes referred to as conscious sedation, is a drug-induced depression of consciousness. A patient who has been sedated in this way is relaxed and generally insensitive to pain, but remains awake and able to respond to verbal instruction. If medically necessary and properly documented, moderate sedation is a separately reported service.

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

1. 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.

If the same provider performs both the primary procedure and the moderate sedation, there must be a trained observer to assist. CPT Assistant (July 2017) provides the following example:

A patient undergoes a procedure 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 procedure, administers the moderate sedation, an independent observer is not required.

2. Whether the patient is younger than five years of age; or five years old, or older.

3. The “intraservice time” of the procedure. Intraservice time begins with the administration of the sedation agent, and ends when the procedure is completed, the patient is stable for recovery status, and the provider performing the sedation ends personal continuous face-to-face time with the patient. Per CPT Assistant(May 2017), “the time spent on postservice activities that are required for moderate sedation are not included when calculating time and selecting the appropriate moderate sedation codes.”

The CPT® codebook includes a helpful chart to determine the proper number of units of moderate sedation to report, based on intraservice time.

And Now… the Codes

The six code you will us to report moderate sedation, with full descriptors, are as follows:

99151 Moderate sedation services provided by the same physician or other qualified healthcare 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 …initial 15 minutes of intraservice time, patient age 5 years or older

99153 Moderate sedation services provided by the same physician or other qualified healthcare 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 healthcare professional other than the physician or other qualified healthcare 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 … initial 15 minutes of intraservice time, patient age 5 years or older

99157 Moderate sedation services provided by a physician or other qualified healthcare 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)

Example Scenarios

The following coding scenarios are quoted from CPT Assistant (June 2017):

Description of Procedure (99152)

The physician or other qualified health care professional performs presedation patient assessment; supervises or personally provides the administration of the sedating agent, with or without an analgesic; and supervises an independent, trained observer who monitors the patient’s level of consciousness and physiologic status throughout the procedure. The patient is assessed continuously throughout the procedure to achieve an effective and safe level of moderate sedation. Additional doses of the sedating agent(s) are ordered or provided by the physician as needed. The physician’s intraservice time ends when the procedure is complete, the patient is physiologically stable, and face-to-face physician time is no longer required.

 Description of Procedure (99155)

The sedating agent(s), with or without an analgesic agent, is administered, and the patient is assessed continuously until an effective and safe level of moderate sedation and/or analgesia is achieved. The patient is closely monitored by the sedating physician and additional doses of sedating and/or analgesic agent(s) are delivered as needed. The sedating physician’s intraservice time ends when the procedure is complete, the patient is physiologically stable, and face-to-face time with the sedating physician is no longer required.

Clinical Example (99157)

A patient undergoes a procedure that requires a physician other than the physician providing the procedure to provide moderate sedation, in order to complete the procedure safely and with minimal emotional trauma. The physician or other qualified healthcare professional providing the moderate sedation personally monitors the patient’s level of consciousness and physiologic status throughout the procedure. …The patient is closely monitored by the sedating physician and additional doses of sedating and/or analgesic agent(s) are delivered as needed.

Sedation Coding Varies for Certain Medicare Services

Coding guidelines as explained the CPT® codebook and CPT Assistant apply in most cases, but not all.

The Centers for Medicare & Medicaid Services (CMS) determined that the moderate sedation work for certain gastro-intestinal (GI) endoscopy procedures differs from that of other endoscopy procedures. As such, CMS designates a 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.

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 intraservice time using 99153.

John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering 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.
John Verhovshek

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John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering 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.

One Response to “Moderate Sedation Coding”

  1. Rajkishore roul says:

    I really appreciate you for those information you have shared.

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