Radiology Coding Alert

These 3 hints keep you aware of moderate sedation use

Don't write off coding "moderate sedation" just because your report doesn't explicitly include those words--there are other clues that may signal your physician's use of moderate sedation.

1. Observer: Moderate sedation requires monitoring by an independent observer, says Michael A. Granovsky, MD, CPC, FACEP, vice president of Medical Reimbursement Systems Inc. in Stoneham, Mass. The observer--often an RN--assists the physician in monitoring the patient's consciousness level and physiological status and remains immediately available until the patient is stable and alert.
 
The rule used to be that as an "independent" observer, this person couldn't be involved in any other part of the related treatment or procedure. However, information presented at the AMA's recent CPT Codes Symposium stated that the independent observer may administer the sedative agents under the physician's direction. Smart: Check your payer's rules about the role of the observer.

2. Drug names: The use of a particular drug may also alert you to conscious sedation, Granovsky says. If your physician provides the drug, you may code it, too.

Common drugs used for conscious sedation include Versed (J2250, Injection, midazolam HCl, per 1 mg), fentanyl (J3010, Injection, fentanyl citrate, 0.1 mg; or HCPCS J1810 , Injection, droperidol and fentanyl citrate, up to 2-ml ampule), and "not otherwise classified" drugs ketamine and diprivan.

3. Documentation: Moderate sedation documentation should include pre- and postsedation patient assessments, administration of the sedation agents, and monitoring of oxygen saturation, cardiorespiratory rates, blood pressure, and body temperature.

Remember: When in doubt, ask the physician to verify that he provided moderate sedation.