In the June 2017 CPT Assistant newsletter, the AMA provides additional information on reporting moderate sedation codes 99151 – 99157. Moderate sedation is more clearly described:
During moderate sedation, cardiovascular function is maintained, spontaneous ventilation is adequate and no interventions are required to maintain the patency of the airway. Moderate sedation is differentiated from deep sedation in which a patient cannot be easily aroused but can respond purposefully by repeated heavy or painful stimulation. Moderate sedation should not be confused with monitored anesthesia care (MAC), which is not a specific level of anesthesia, rather it is a spectrum of services and the provider responsible for them must be prepared and qualified to convert to general anesthesia when necessary.
In addition, the AMA specified the medication that is administered to achieve moderate sedation. The drugs administered for moderate sedation are typically a benzodiazepine such as midazolam. It can be administered alone or in combination with an opioid analgesic, such as fentanyl or morphine. Oral medication may also be administered.
The AMA has not addressed why physicians may not report code 99153 in the hospital setting. This article from CGS Administrators, the Medicare Administrative Contractor for Jurisdiction 15, provides a good explanation of rationale:
Clarification of CPT Code 99153
Code Descriptor: 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 (list separately in addition to code for primary service).
Billing for moderate sedation services (CPT Codes 99151 or 99152) represents the first 15 minutes of service. All physician work (as defined by AMA CPT: physician or qualified health care professional) occurs during that first 15 minutes. Please note: Physicians who are performing the procedure do NOT have to actually inject the drug, but MUST supervise and have face-to-face supervision at the time of the injection. Usually thereafter, the physician is engaged in performing the procedure, and a nurse will monitor the patient.
The CPT code 99153 represents additional time performed by the nurse (or other personnel). Since the nurse is employed by the facility, incident to billing is not appropriate. Therefore, CPT code 99153 is not payable to the physician since that nurse does not work for him/her, hence the PC/TC indicator 3. There is no physician work involved since he/she is engaged in performing the procedure and the nurse is not employed by the physician. Therefore, the physician cannot bill for the nurse’s services. In an office setting where the nurse is employed by the physician, the code will be billable and the practice will get the value of the facility side of the payment (ie. Practice expense and malpractice expense)
CMS has categorized the code with the PC/TC indicator 3 because it essentially behaves like a technical component only code, since there is no physician work.
This is a notification to let you know there are changes for physician billing for Moderate (Conscious) Sedation during Cath Lab procedures for 2017. Moderate (Conscious) Sedation is no longer bundled into the CPT Procedures codes, therefore if the service is provided, a physician can bill for Moderate (Conscious) Sedation separately in 2017;, if AMA guidelines have been met and documented appropriately. The RVU’s for the cardiac procedures codes have been reduced to reflect this change. This includes many interventional, electrophysiology and some echocardiography services. CPT 99152 and 99153 will pertain to most Cath Lab procedures. CPT 99153 is technical only and it has been suggested that this code is not being reimbursed by CMS. It has been suggested that CMS is only wanting to reimbursement for the RVU amount removed from the procedures. (RVU 0.25). Therefore only the initial 15 minutes is reimbursable by CMS. It is unknown if other payers are reimbursing for the additional time codes. CPT Manual and CMS do not agree at this time.
There must be a trained observer to perform patient monitoring that is supervised by the physician. Moderate sedation codes are determined based on the face-to-face time the physician has with the patient during the sedation (this time is only calculated based on the “intra-service work” time). The physician must be present when the sedation is administered, which is the start time used for tracking the time. The sedation time ends when the physician is no longer required to have face-to-face time with the patient – the patient is stable enough to move on to recovery. If the physician interrupts the face-to-face time with the patient, conscious sedation time is ended.
In the procedure report, the physician should document at a minimum the use of an independent trained observer and the amount of face-to-face time spent with the patient. Moderate sedation is reported in 15 minute increments, there must be at least 10 minutes of Conscious Sedation to bill for the initial 15 minutes.
Examples of how to document in your Op report Moderate Sedation 2017
• Under my direct supervision, intravenous moderate sedation was administered during the course of this procedure, with continuous monitoring of hemodynamic parameters. Total time of sedation was 45 minutes.
• The patient was given conscious sedation by a registered nurse with me in attendance. The agents used were fentanyl and Versed. There was continuous monitoring of EKG, blood pressure and pulse oximetry. Total time for conscious sedation was 1 hour.
• Moderation sedation was achieved with Versed (4mg) and Fentanyl (150mcg) as well as 4mg of Zofran. Monitoring of the patients vital signs and respiratory status was provided by trained nursing staff during the entire course of the procedures and under my supervision and recoded in the patient’s medical record. The duration of