Question moderate sedation

jmgiles

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I need a second opinion on the documentation requirements for moderate sedation. I feel that the operative note must state that the physician: 1) administered or supervised the administration of moderate sedation, 2) the meds used, 3) an independent observer monitored the patient, and 4) the intraservice time. The physician is saying that he does not need to document any of this. He is saying that all he must document is the meds used and that everything else is in the nurse's note. He's refusing to add any of the other information into the note and demanding that I re-bill for moderate sedation. That just doesn't seem right to me. I've been taught that if it's not in the operative note then it didn't happen. Am I wrong or being too stringent?
 
You are correct,
  • The intraservice time is the only time that can be counted to determine the assignment of the CPT code(s);
  • CPT has defined the intraservice time as “It begins with the administration of the sedation agent(s), requires continuous face-to-face attendance, and ends when the personal face-to-face time ends with the patient”;
  • It is important that you use language that mirrors CPT terminology, other terms used, such as “total time spent was…” or “encounter time was…” cannot be counted;
  • The pre-sedation and post-sedation work is required however, none of this time can be calculated to determine code selection;
  • Because having a trained independent observer is required be sure to include this information in your documentation;
  • The only documentation that will be used to determine codes submitted is “Intraservice time was…”;
  • Do not include any of the preservice and postservice work when calculating the intraservice time.
The report needs to stand alone with all the information above.
 
You are correct. The physician must include all of that in the op report, otherwise you can’t bill for it. We have a physician that has near perfect documentation, but continues to use total time instead of start and stop time. It’s very aggravating! :p
 
I completely agree with both replies above. The CPT is very specific as to what documentation is required. If the physician or practice is audited on moderate sedation the payer is going to demand all those payments back as undocumented. I have had to educate physicians that this is now required by payers and they can't just continue past practices. It is very aggravating, but you have to stand firm with them. Hope this helps! :)
 
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