nabernhardt
Guest
- Messages
- 234
- Best answers
- 0
I am needing some help please with how other facilities are coding and billing moderate sedation when performed by a CRNA. And any resources would be helpful too.
Hi. Need some help with moderate sedation. Our physicians do not normally do moderate sedation, however here and there they will, so when they actually perform moderate sedation on patients, do they have to actually dictate on the report that they injected it or that it was injected in their presence, OR can they just say the type of sedation it was and what time it began and ended OR does it have to be in the op note at all, can it just be in the patient's record somewhere, like in the nurse's notes? Just trying to cover all my basis here??? Thank you in advance
Here is a good resource. https://www.physicianspractice.com/coding/coding-moderate-sedation-different-2017
Moderate sedation is a separately reportable service when performed with procedures and CPT requirements are met. Moderate sedation is reported with CPT codes 99151-99157.
In order to report moderate sedation, documentation must include the following elements:
The age of the patient
The sedating agents administered
The physician supervised the moderate sedation
The total intraservice time of the moderate sedation (administration of sedating agent to completion of procedure)
An independent, trained observer was present and monitored the patient throughout the procedure with no other duties performed
The sedating agents administered
Thank you so much, this has been very helpful!, Can you help me find where in the guidelines it states that the doctors have to document this information? I would like to have it to show them when I inform them, but I have not been able to find it in the moderate sedation/medicine section guidelines? Not sure if I'm looking in the right spot?
I am needing some help please with how other facilities are coding and billing moderate sedation when performed by a CRNA. And any resources would be helpful too.