Revenue Cycle Insider

Question: Sometimes a trained observer monitors the patient undergoing sedation while a physician performs the procedure. What certifications does a “trained observer” need and are their services reported separately from the anesthesia coding or procedure coding?

Codify Subscriber

Answer: CPT^® defines an independent trainer observer as “an individual who is qualified to monitor the patient during the procedure, who has no other duties (eg, assisting at surgery) during the procedure.” So, while there aren’t any specific credentials or qualifications detailed by CPT^®, trained observers must meet requirements according to respective state law, facility policy, credentialing rules, and scope-of-practice rules, in addition to being able to knowledgably monitor the patient’s level of consciousness and physiologic status during moderate sedation.

The observer must be independent of the procedure itself and dedicated to monitoring; they can’t simultaneously assist with the procedure.

There aren’t any individual codes to account specifically for a trained observer’s role, nor would you separately report an anesthesia service or other moderate sedation code for a trained observer, because their work is inherent to the requirement described in 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) to +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)) — when the physician or other qualified healthcare professional (QHP) performing the diagnostic or therapeutic procedure also provides the moderate sedation.

If a different physician or other QHP provides the moderate sedation service, codes 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) to +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)) may apply. These describe a separately reportable sedation service furnished by another physician or QHP, rather than the observer’s monitoring activities.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC