Wiki HELP - Moderate Sedation for two separate procedure notes

[maryir]

I'm holding these services until I can get a definitive answer -
I have a GI physician who is charging for Moderate Sedation while performing two separate procedures, an EGD and a Colonoscopy. The Moderate Sedation is noted in one note (the Colonoscopy) describing the Moderate Sedation, which includes the time recorded for both the Colonoscopy and EGD.
The Dr is stating that he performed one procedure immediately after the other and that the documentation of the Moderate Sedation within the one note is sufficient.
I’m stating each note must be independent. That the Moderate Sedation should be noted in both notes.
Am I looking at this wrong?

 

[JenniferB7]

You are going to want to check your insurance payer guidelines for documentation requirements. Each insurance payer may have specific requirements, such as Palmetto GBA (see page 20), which requires a completely separate note for moderate sedation:

Documentation must include a separate anesthesia note with a patient assessment, the method and route of administration of conscious sedation, start and stop times, baseline vital signs, vital signs every 5 to 15 minutes (depending on patient status), identity of trained observer (for CPT codes 99143–99145), method of monitoring heart rate, oxygen saturation (if any) and recovery time. ​

While the codes have changed since this was written in 2013, the documentation requirements have not changed.

In general, it is best to have a separate note for moderate sedation that includes the information above. I have found that this satisfies most, if not all, insurance payer requirements.

Palmetto GBA link: https://engage.ahima.org/HigherLogic/System/DownloadDocumentFile.ashx?DocumentFileKey=9af2a07d-26e1-4694-b1de-a4c59d0dbc30