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Thread: coding moderate sedation

  1. #1

    Question coding moderate sedation

    AAPC: Back to School
    does moderate sedation mean no anesthesiologist is involved? I just had two different endoscopic examinations which in CPT state conscious sedation is included but there was an anesthesiologist involved and i sure wasn't conscious. Please explain. thanks

  2. #2
    Join Date
    Apr 2007
    Lubbock, TX


    Just because you don't remember it doesn't mean you weren't awake. When I had dental surgery a few years ago, they couldn't put me all the way under, because I had to be responsive to them telling me to open and close my mouth, but I don't remember any more about that procedure than when I had my gallbladder out. Either way, an anesthesiologist has to be present because you're sedated enough that someone needs to monitor your breathing and make sure that you're not having a bad reaction to the drugs. Hope that's helpful...

  3. #3


    Actually you do not have to have an anesthesiologist present for moderate sedation... a physician and nurse are mostly all that is used in the ER setting or office setting.

  4. #4
    Join Date
    Apr 2007
    Bangor, Maine


    CPT Book, 2010 (& 2009)
    Appendix G-Paragraph 2

    "Since these services inlcude moderate sedation, it is not appropriate for the same physician to report both the service and the sedation codes 99143-99145. It is expected that if conscious sedation is provided to the patient as part of one of these services, it is provided by the same physician who is providing the service."

    Also read the other paragraphs in this Appendix. It explains a lot about conscious sedation and anesthesia services. You can also read over the Anesthesia guidelines on page 40 of the CPT book. It may help to clear up the difference between the two.

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