General Surgery Coding Alert

Question: Should we report 99144 and +99145 when the surgeon documents 36 minutes of moderate sedation for a procedure such as 48500 (Marsupialization of pancreatic cyst)?

Vermont Subscriber

Answer: No -- 36 minutes of moderate sedation earns only 99144 (Moderate sedation services [other than those services described by codes 00100-01999] provided by the same physician 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; age 5 years or older, first 30 minutes intra-service time).

CPT® guidelines state, "A unit of time is attained when the mid-point is passed." That means to meet the requirement for +99145 (... each additional 15 minutes intra-service time [List separately in addition to code for primary service]), the time needs to be at least 7.5 minutes (half of 15 minutes) beyond the 30 minutes you report with 99144. The 36 minutes in your case do not meet the 37.5 minute requirement.

Don't forget to apply the rule to 99144, as well. If a case doesn't involve 16 minutes or more of moderate sedation, you should not report 99144.

CPT® Assistant (October 2011) confirms that these time guidelines apply to the moderate sedation codes. Payer guidelines may differ from (and trump) CPT® guidelines for their own claims, but at least one Medicare Administrative Contractor (MAC) has instructed its providers to follow the midpoint rule. Part B MAC NGS posted "Time Requirement to Report Moderate Sedation" as a Feb. 21, 2012, news article on its site. The notice also states, "When no written policy exists Medicare does follow CPT® guidelines."

Keep in mind: Many surgical codes are listed in CPT® Appendix G indicating that moderate sedation is included in the code. For those codes, you should not report moderate sedation codes separately.