Question Minimal sedation


Evansville, Indiana
Best answers
I code Physiatry for the practice I work for (I have only been doing it for about a year). I have a few questions re the line between minimal sedation and moderate/conscious sedation. One of my doctors has recently started added anxiolysis when dictating the procedure note. I have searched all my books, materials, co-workers & the web and I am still left with a few questions. I know that Anxiolysis is defined as minimal sedation, as far as I can tell, you can't code minimal sedation. Below my questions is a copy of part of the procedure note.
1. Other than stating on the pcr note "anxiolysis" minimal sedation determined by the injection medication or amount? Does that have anything to do with it?
2. What is the line between minimal vs. moderate/conscious sedation? I have read the difference but they sound very similar.
2. Is there anything that can be coded for this type of sedation? We are not in a hospital setting, we own the equipment and building.
3. I want to understand and be able to locate any verbiage that I can, if needed to query my doctor.

Type of Procedure:
Fluoroscopic Left L4/L5 Transforaminal ESI

Pre-Procedure Diagnosis: Lumbar stenosis and neurogenic claudication

Post-Procedure Diagnosis: Lumbar stenosis and neurogenic claudication

Description of Procedure:
Anxiolysis: Versed 2mg IVP

Consent: The risks, benefits, and alternatives to the procedure and sedation were discussed with the patient and they was given the opportunity to ask questions prior to signing the consent.

Then the rest of the pcr note......