Advanced Search

Anesthesia Coding Alert

Reader Question:

First Failed Moderate Sedation Should Be 995.24

Published on Wed Oct 10, 2012

Question: Sometimes our anesthesiologist is asked to provide MAC (monitored anesthesia care) when the referring doctor can't sedate the patient. How do we handle the first instance? Texas SubscriberAnswer: If you're coding for the first time the patient experiences a failure to be sedated, the most appropriate diagnosis is 995.24 (Failed moderate sedation during procedure). Verify that documentation includes details regarding the surgeon's and anesthesiologist's work and the patient's response. Future care: If one of your anesthesiologists treats the patient again, the record should note the failed sedation. The situation would then be considered part of the patient's history, so include diagnosis V15.80 (Personal history of failed moderate sedation).
You’ve reached your limit of free articles. Already a subscriber? Log in.
Not a subscriber? Subscribe today to continue reading this article. Plus, you’ll get:
  • Simple explanations of current healthcare regulations and payer programs
  • Real-world reporting scenarios solved by our expert coders
  • Industry news, such as MAC and RAC activities, the OIG Work Plan, and CERT reports
  • Instant access to every article ever published in your eNewsletter
  • 6 annual AAPC-approved CEUs*
  • The latest updates for CPT®, ICD-10-CM, HCPCS Level II, NCCI edits, modifiers, compliance, technology, practice management, and more
*CEUs available with select eNewsletters.

Other Articles in this issue of

Anesthesia Coding Alert

View All