MODERATE (CONSCIOUS) SEDATION – EXTENSIVE CHANGES FOR 2017

Currently, for most of the interventional procedures you perform, reimbursement for moderate sedation is bundled into the procedure code, but that will soon change. For dates of service on or after January 1, 2017, reimbursement for the procedure and the moderate sedation will be separated.

The AMA created new moderate sedation codes with new descriptions and new guidelines.  The purpose of this newsletter is to first, show you how your reimbursement will change and second, clarify the words you need to use to meet the documentation requirements.  

REIMBURSEMENT 

Since moderate sedation will be unbundled from the procedure codes, you will notice a reduction in the reimbursement for these codes.  But that doesn’t mean you won’t get paid, all it means is that if you perform the sedation and provide supporting documentation, separate moderate sedation code(s) will be additionally assigned.  To better explain, see how the reimbursement changes from 2016 to 2017 in the example below:

Scenario – Insertion of an IVC filter and moderate sedation – 30 minutes of intraservice time. 2016 vs 2017:

• 2016 – Total reimbursement $244.75 – Explanation: A single CPT code is assigned – 37191 Insertion of IVC filter.  Moderate sedation is bundled into CPT 37191
• 2017 – Total reimbursement $254.33 – Explanation: Three CPT codes are assigned: 37191 ($231.77) Insertion of IVC filter, 99152 moderate sedation, initial 15 minutes ($12.32), and moderate sedation 99153 ($10.24) each additional 15 minutes. 

Note:  For hospitals billing under OPPS, the moderate sedation has been determined to be incidental and the reimbursement is bundled. 

DOCUMENTATION REQUIREMENTS 

The codes to report moderate sedation include all three components, the preservice work, intraservice work, and the postservice work.  But it is the intraservice work that drives the selection of codes by time.  Below you will find a brief summary of what constitutes each component as defined by CPT.

Preservice Work

The following preservice work components are not included when determining the intraservice time: 

• Assessment of past medical and surgical history with emphasis on cardiovascular, pulmonary, airway, or neurological conditions;
• Review of the patient’s previous experiences with anesthesia and/or sedation and family history of sedation complications; 
• Summary of the patient’s present medication list; 
• Drug allergy and intolerance history; 
• Focused physical exam with emphasis on: 
  1. Mouth, jaw, oropharynx, neck and airway for Mallampati score assessment; 
  2. Chest and lungs;
  3. Heart and circulation 
• Vital signs, including heart rate, respiratory rate, blood pressure, and oxygenation with end tidal CO2 when indicated; 
• Review of any pre-sedation diagnostic tests; 
• Completion of a pre-sedation assessment form; 
• Patient informed consent; 
• Immediate pre-sedation assessment prior to first sedating doses; and 
• IV access and fluids.

Intraservice Work 

Because it is the intraservice time (only) that is used to determine the appropriate moderate sedation CPT code(s), it is imperative that you are aware of how CPT defines it: 

• Begins with administration of the sedating agent(s); 
• Ends when the procedure is completed, the patient is stable for recovery status, and the physician or other qualified health care professional providing the sedation ends personal continuous face-to-face time with the patient; 
• Includes ordering and/or administering the initial and subsequent doses of sedating agents; 
• Requires continuous face-to-face attendance by the physician or another qualified health care professional 
• Requires monitoring patient response to the sedating agents; 

If you are performing the procedure you would be required to supervise and direct an independent trained observer who will assist in monitoring the patient’s level of consciousness and physiological status throughout the procedure. 

Postservice Work 

Once the continuous face-to-face time ends, additional face-to-face time cannot be added to the intraservice time, however, it is part of the postservice work.  The following postservice work components are not included, when determining intraservice time for reporting:

• Assessment of the patient’s vital signs, level of consciousness, neurological, cardiovascular, and pulmonary stability in the post-sedation recovery period;
• Assessment of the patient’s readiness for discharge; 
• Preparation of the documentation; 
• Communication with the family/caregiver regarding the sedation.  

Reimbursement 

• Beginning January 1, 2017, moderate sedation will no longer be bundled into the procedure code.  Because of this, you will notice a slight decrease in reimbursement for the procedure code but providing there is supporting documentation, the revenue is not lost.  Additional CPT codes for moderate sedation can be assigned;
• Mirror CPT terminology. “Total intraservice time was…” will be counted and reimbursed;
• For 2017 reimbursement, see table below. 

Documentation 

• 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.

REFERENCES

• 2017 CPT Professional Edition 
• CGS Medicare 2017 MPFS 

If you have a documentation issue that you would like to see covered, please contact Wendy Block, CPC, RCC, and CIRCC at wblock@streamlinemd.com or by phone at 330.564.2618