conscious sedation with MRIs

tmorehart

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Is it appropriate for me to code for conscious sedation with an MRI? The patient had an MRI of the right and left shoulder and the brain and the physician documented intravenous conscious sedation with 7 mg of Versed and 100 mcg of fentanyl administered for a total of 2 hours for all 3 procedures.
 

donnajrichmond

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Is it appropriate for me to code for conscious sedation with an MRI? The patient had an MRI of the right and left shoulder and the brain and the physician documented intravenous conscious sedation with 7 mg of Versed and 100 mcg of fentanyl administered for a total of 2 hours for all 3 procedures.
MRIs do not include moderate sedation, so if your physician was face-to-face with the patient for 2 hours doing both the MRI and supervising the sedation (and with the presence of a trained observer), then you can code MS separately. Only face-to-face physician time can be counted toward moderate sedation, so if he gave the order but didn't stay with the patient, you cannot code.
 

tmorehart

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Thank you! He didn't document that he was with the patient the entire time. I am not going to bill for the moderate sedation.
 
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