99144 Conscious Sedation in Pain Management Office

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273
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Scotia, NY
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Hello,

I was wondering if someone can assist me in how to document for Conscious Sedation in an office setting for Pain Management. We currently just use something like "Per patient request, the patient was then administered 2 mL of 2 mg/2 mL midazolam IM by the nurse." I am received denials from United Health Care. Should we be reporting time, etc? If I can get a sample of this I would greatly appreciate it.

Thank you

Melissa Harris, CPC
The Albany and Saratoga Centers for Pain Management
 

CodingKing

True Blue
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Worcester, MA
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According to the United Health conscious sedation payment policy:

UnitedHealthcare will allow separate reimbursement for moderate sedation services reported using CPT codes 99143-99145 when provided by the same physician performing the medical or surgical procedure except for:

1) All procedures listed in Appendix G of the CPT book
2) Anesthesia procedures (CPT codes 00100-01999)
3) CPT and HCPCS codes that are part of CMS National Correct Coding Initiative (NCCI) edits

These procedures include moderate sedation as an inherent part of providing the service.
 

KMCFADYEN

Expert
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Roanoke, VA
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This is a time based code so time is one of the most important items to document. There should be a report of vitals that are taken at certain increments as well.
 
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