Moderate Sedation

sp485

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Does anyone know if it is a requirement for the physician to state the total moderate sedation time in the report?:)
 
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99143-50 are time based

The moderate sedation codes are time based, so yes, the time must be recorded in the documentation of the service. Note, CPT specifically requires that the time be intra-service time, and the guidelines give specific instructions as to what is and is not included in the intra-service time. (2008 CPT professional edition, page 435).

F Tessa Bartels, CPC, CPC-E/M
 
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mrce@tampabay.rr.com

Can anyone tell me if sedation codes can be assigned when only "total time" is documented in a hospital outpatient setting. The record does not indicate start/stop time?

Debra
 
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For Facility-

Per the CPT book, you need the start time of the administration of the sedating product and the end time of the face-to-face service has ended. Please make sure to read the 2017 CPT book about the Pre, Intra and Post Service work. Make sure that you have the other required documentation, example- periodic assessment of the patient.:)
 
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