Anesthesia Coding Alert

Find clarity when reporting moderate sedation.

Moderate sedation is a drug-induced state of depressed consciousness in which the patient is able to respond purposefully to verbal commands, whether alone or in combination with light tactical stimulation.

Moderate sedation services must be 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.

Keep reading for more information on moderate sedation and how to report relevant procedures.

Become Familiar With These CPT^® Codes

Coders can report moderate sedation with these CPT^® codes:

• 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 … 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)) Use this code in conjunction with 99151 or 99152.
• 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)). Use this code in conjunction with 99155 or 99156, but do not use it with 99151 or 99152.

When less than 10 minutes of moderate sedation is performed, the service is not separately reportable. These services are age-specific and codes +99153 and +99157 are for each additional 15 minutes in the hospital, for facility fee only.

Note: The medically unlikely edit (MUE) for the add on code 99153 is 9 units and the MUE for 99157 is 6 units.

Important: Moderate sedation codes 99151, 99152, +99153, 99155, 99156, and +99157 are not used to report administration of medications for pain control, minimal sedation (anxiolysis), deep sedation, or monitored anesthesia care. The appropriate codes for those services would be 00100 (Anesthesia for procedures on salivary glands, including biopsy) though 01999 (Unlisted anesthesia procedure(s)).

Moderate sedation may be used for a variety of procedures, including endoscopies, breast biopsies, minor bone fracture repairs, and percutaneous vascular interventions. The Centers for Medicare & Medicaid Services (CMS) has determined that moderate sedation used for certain gastrointestinal (GI) procedures is different than other endoscopic procedures. Coders should report 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 (additional time may be reported with 99153, as appropriate))  instead of 99151through +99153 when reporting moderate sedation for Medicare patients, in addition to designated GI procedures. For facility coding, code +99153 can be used for each additional 15 minutes of intra-service time.

Moderate sedation is typically achieved with intravenous (IV) administration of a short-acting benzodiazepine (e.g., midazolam), either alone or in combination with an opioid analgesic (e.g., fentanyl or morphine). Oral pre-medication and/or preemptive analgesics may also be administered.

Know These Documentation Requirements

For purposes of reporting, intra-service time of moderate sedation is used to select the appropriate code(s). The following definitions are used to determine intra-service time (compared to pre- and post-service time). Pre- and post-service work must also be documented in the patient’s chart.

Intra-service time is used to determine the appropriate CPT^® code to report moderate sedation services. For coding purposes, intra-service time:

• Begins with the administration of the sedating agent(s);
• Ends when the procedure is completed, the patient is stable for recovery status, and the physician or other qualified healthcare 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 of the physician or other qualified healthcare professional;
• Requires monitoring patient response to the sedating agents, including:
  • Periodic assessment of the patient;
  • Further administration of agent(s) as needed to maintain sedation; and 
  • Monitoring of oxygen saturation, heart rate, and blood pressure.

If the physician or other qualified healthcare professional who provides the sedation services also performs the procedure supported by sedation (99151, 99152, +99153), the physician or other qualified healthcare professional will supervise and direct an independent trained observer who will assist in monitoring the patient’s level of consciousness and physiological status throughout the procedure.

Documentation should also include any references to additional medical record forms that provide details to support the moderate sedation code (e.g., cath lab report). Best practice is that the physician also documents the drug name being administered.

Documentation Examples

Here are a few clinical examples for moderate (conscious) sedation:

• “Moderate sedation was performed on this 3-year-old patient with Midazolam under my direct supervision over the RN (ITO), vitals were monitored throughout the procedure, with a total face to face time of 16 minutes. Exact start and stop times can be found in the Cath lab report.” Coding: 99151
• “Moderate sedation was administered using Propofol 50mg under my direct supervision of the RN (ITO) for the entire procedure including vitals including additional dose of the sedating agent for a total time of 45 minutes (12:15-1:00pm). Full report scanned to patients’ chart. Coding: 99152/+99153. 99152 can be billed by the provider for the professional fee for the first 15 minutes, 99152 and +99153 x 2 can be billed by the facility for the entire 45 minutes spent. Use +99153 in conjunction with 99151, 99152.
• “Moderate sedation was performed and monitored by Dr. X using Fentanyl for this 4-year-old patient. Total face-to-face time was 25 minutes (11:20-11:45am).” Coding: 99155.
• “Dr. X administered and monitored the sedating agent for this procedure including vitals from 10:00-11:00am (60 minutes).” Coding: 99156/+99157. 99156 can be billed by the provider for the professional fee for the first 15 minutes and 99156 and +99157 x 3 can be billed by the facility for the entire 60 minutes spent.

Cristin Robinson, CPC, CPMA, CCC, CRC, Contributing Writer