Wiki Continuous Moderate Sedation

[Pam Nealy]

Can a physician bill for continuous moderate sedation that is performed for 72 hours while the patient received MIBG therapy? The physician is not providing the MIBG therapy and will only be responsible for the sedation. The physicians performing the sedation will be at the bedside for the entire time the treatment is provided. The patient will have continuous sedation via pump, monitored by our providers for the entire duration of the therapy. Thanks for any assistance as I am not familiar with moderate sedation performed for this continuous length of time.

 

[jkyles]

Hi there, that's some marathon care. I think medically unlikely edits will block payment for most of that time. For example, Medicare's MUEs allow a total of 1 hour 45 minutes for moderate sedation. That's 15 minutes for the primary code and 6 units of 15 minutes for add-on code 99157. This might be a situation where a conversation with a payer rep ahead of time is your best bet.

 

[Pam Nealy]

Hi there, that's some marathon care. I think medically unlikely edits will block payment for most of that time. For example, Medicare's MUEs allow a total of 1 hour 45 minutes for moderate sedation. That's 15 minutes for the primary code and 6 units of 15 minutes for add-on code 99157. This might be a situation where a conversation with a payer rep ahead of time is your best bet.

Thanks. That was my thought also but I am being pushed because Medicare is not the payor. Contacting the payor is a great suggestion!

 

[jkyles]

Sure. Even though a lot of payers use the NCCI edits or have their own systems they might be more flexible for for a specific treatment for a pediatric patient.

BTW, if it is Medicaid, the NCCI files are here https://www.cms.gov/medicare/coding-billing/ncci-medicaid/medicaid-ncci-edit-files.