Observe These Rules When Reporting Cardiac Catheterization With Moderate Sedation
Coding hinges on who’s providing which services. Cardiac catheterizations are very commonly billed with conscious (moderate) sedation. Moderate sedation is measured by intraservice time, which begins when the administration is given and ends when the procedure is complete. You should not report pre- and post-service time separately. You can only bill this service once after at least 10 minutes of sedation has been provided. Qualified healthcare professionals (QHP) who are allowed to bill moderate sedation include doctors (MDs/DOs), nurse practitioners (NPs), physician assistants (PAs), certified registered nurse anesthetists (CRNAs), clinical nurse specialists (CNS), and anesthesiologists. Recognize These Circumstances The most common scenarios for cardiac catheterizations with moderate sedation are when the provider who is performing the procedure also supervises the monitoring of the sedation. In these cases, the provider must document the medication given to the patient, the start and end time, and that an independent trained observer was present for the entire procedure. This scenario would support 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) for the first 15 minutes for patients 5 years and older. Pay attention to the payer’s specific policies for this service. For instance, Medicare considers +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) a technical-only code and will only reimburse the provider for 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) or 99152 as appropriate. When in doubt, always check the individual payer policies for guidance on proper billing. When billing for the facility side, you can bill the add-on code +99153 for each additional 15 minutes with up to 2 units. Now, look at this scenario and see how you would bill it for a separate QHP. All of the same elements are required, but in the case of a separate QHP, the appropriate code for a patient age 5 years or older would be 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) for the first 15 minutes. The same rule applies in this case, where the facility can also bill for an additional 15 minutes up to 2 units with add-on code +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). CPT® categorizes these sedation codes by age and provider. Moderate sedation codes include: Age categories are younger than 5 years of age or older than 5 years of age. Coders should always reference the CPT® code book for additional information. In the CPT® code book, there is extensive guidance with a time chart to assist with appropriate moderate sedation billing. Consider This Clinical Encounter Clinical Background: A 74-year-old patient presents with exertional chest pain and abnormal stress test results. The cardiologist schedules a left heart catheterization with coronary angiography. The facility does not have anesthesia coverage available for routine Cath lab cases. Instead, a hospitalist (MD) credentialed for procedural sedation is assigned to provide and monitor moderate sedation during the procedure. Procedure(s) Performed: Left heart catheterization; Selective coronary angiography (left and right coronary arteries) Coronary Angiography Left Main: Large caliber, no significant stenosis LAD: 80% proximal stenosis; mid and distal segments with mild irregularities LC: Non-dominant, mild luminal irregularities RCA: Dominant vessel; 40% mid-segment stenosis Left Heart Catheterization A pigtail catheter was advanced across the aortic valve into the left ventricle. LVEDP: 12 mmHg No gradient across the aortic valve Left Ventriculography: Performed in RAO projection. LVEF: 55% The catheters and sheath were removed. Hemostasis achieved with TR band. The patient tolerated the procedure well with no complications. Providers Involved: Interventional Cardiologist - performs the left heart Cath Hospitalist (MD) - provides and monitors moderate sedation Cath Lab RN - assists with monitoring and documentation Sedation Details: Moderate sedation administered by the hospitalist Drugs administered documented: Start time: 10:12, Stop time: 10:32; Total sedation time: 20 minutes. Patient remained responsive to verbal stimuli. Continuous monitoring documented. Codes: For the cardiologist’s services, report 93458 (Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed) with modifier 26 (Professional component). For the hospitalist, who’s employed by the facility, code 99155 and +99157. The cardiologist does not bill for any portion of the sedation as they did not administer or supervise the service. Since the hospitalist is employed by the facility, they can bill the initial service for the first 15 minutes and 1 unit for the add-on code based on the total sedation time. Cristin Robinson, CPC, CPMA, CCC, CRC, CEMC, AAPC Approved Instructor,
Education Coding Consultant, Bristol, Tennessee
