Radiology Coding Alert

Losing track of time could be a compliance risk

Brush up on your addition skills before reporting the new codes for moderate sedation.

The new moderate sedation codes are time-based and represent 30 minutes of “intra-service” time. (See “Keep Your Eyes Open for New Moderate Sedation Codes” on page 3 for complete definitions of the new codes.) CPT Codes 2006 spells out how you should start and stop the clock to properly record for this service, and you need to make sure you keep an eye on these three elements:

• start recording intra-service time when the provider administers the sedation agent

• document continuous face-to-face attendance by the providing physician

• stop intra-service time when the providing physician ends personal contact. If these steps require more than 30 minutes, you can now report the additional time, in 15-minute increments, with add-on code +99145 (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; each additional 15 minutes intra-service time [list separately in addition to code for primary service]).

If performing sedation at the request of another physician, code additional time using +99150 (Moderate sedation services [other than those services described by codes 00100-01999], provided by a physician other than the healthcare professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes intra-service time [list separately in addition to code for primary service]).

Important: Don’t confuse “intra-service” time for moderate sedation with general anesthesia reporting guidelines. For sedation, unlike anesthesia, you should not include an initial assessment of the patient or the establishment of IV access and fluids (when required) in the reported time.