Wiki Moderate conscious sedation


Billings, MT
Best answers
I'm new to anesthesia coding and have kind of a basic silly question. Is there ever a time when an anesthesiologist would be billing for just moderate conscious sedation alone? Our anesthesiologist is attending surgeries at a small surgery center. I'm assuming he's doing monitored anesthesia care but we questioned if there was ever a time when he's just doing moderate sedation. We're second guessing ourselves. Some of the procedures (but not all) are just super basic like cataracts and cavities in children.
Based solely on my own experience with anesthesiologists, I would say, usually, no, primarily because the surgeon could provide this service and because the anesthesiologist is not likely to be reimbursed for the service. However, the anesthesiologist's documentation should indicate the type of sedation. You should never have to assume it was MAC. If MAC isn't documented, you probably shouldn't be billing for it. I would look for the method of sedation in the record and, if it isn't clear, query the provider before billing.