Moderate Sedation - Trained observer


Oshkosh, WI
Best answers

Our providers are fighting us tooth and nail about adding the name of the trained observer during the time they are administering moderate sedation. I am finding that this should be in their documentation so we are able to bill the new 2017 moderate sedation code(s).

They say there are many people that float in and out of the department occasionally that they are unable to learn everyone's name so when there is a trained observer present during the duration of the sedation time they would like to document "patient was observed by trained nursing staff for the duration of the procedure".

I originally educated to them that they should be stating that observers name for sure and credentials if possible. And since they brought up the issue above I have been trying to research if that is acceptable and am unable to find a concrete answer. Reaching out to all of you to see if you have any insight on this.

So in short, can the provider performing the procedure state "nursing staff was present during the procedure to observe the patient"

Thank you all!


Victoria, TX
Best answers
While I can't find anything that specifically states the observer's name and credentials are required, it is something that an insurance carrier or court would look for in the event of an audit or a liability claim. The CPT codes for moderate sedation state "an independent trained observer" and CPT guidelines state that "an independent trained observer is an individual who is qualified to monitor the patient during the procedure, who has no other duties (eg, assisting at surgery) during the procedure." As an auditor, I am looking for the name and credentials of one specific person. From an auditing perspective (let alone a liability one), it would be impossible the requirements of the CPT code since the description itself requires you to document that you had an "independent trained observer". A general statement to the existence of "nursing staff" would not meet that requirement as an auditor or court can't verify that the observer is a "independent", "trained", or otherwise "qualified" under CPT or payer policy without a name and credentials.

Palmetto GBA (Medicare) states on page 19 of their 2013 anesthesia guide that the name and credentials of the independent observer are required documentation:

Here are some related articles that may be helpful:

Given that this is new for 2017, I expect more guidance to be forthcoming over the course of this year.

Hope that helps!

Jennifer M. Connell, CPC, CPCO, CPC-P, CPB, CPMA, CPPM, CPC-I, CENTC