Documenting and coding for Moderate Sedation continues to challenge providers and the purpose of this article is to help clarify AMA guidelines. Below, we review Moderate Sedation codes, descriptions and RVUs to help you understand the nuances.
Moderate Sedation Components
There are three components to administering Moderate Sedation, CPT codes 99151 – 99157:
- Preservice work – patient assessment, informed consent, medication orders, equipment setup, patient preparation, and communication.
- Intraservice – Begins with the administration of sedating agents, ends when the procedure is completed, the patient is stable for recovery, and the physician or other qualified healthcare professional providing sedation and personal continuous face-to-face time with the patient. It also includes ordering and administering the initial and subsequent doses of sedating agents, requires continuous face to face attendance of the physician or other qualified healthcare professional, requires monitoring patient response to the sedating agents including periodic assessment of the patient, further administration of agents as needed to maintain sedation and monitoring of O2 saturation, heart rate and blood pressure.
- Post service – Once continuous face-to-face time with the patient has ended, additional face-to face time with the patient is not added to the intra-service time for the following services. Assessment of vital signs level of consciousness neurological cardiovascular and pulmonary stability. Assessment of the patient’s readiness for discharge, preparation of the documentation, or communication caregiver regarding the sedation.
Moderate Sedation Codes – How to Use Them
There are a total of six codes broken down by age, performing provider, same or different provider, performing the procedure for the first 15 minutes and each 15-minute increment after the initial.
- The intraservice time drives the selection of code(s) by time, which is based on patient/physician face-to-face time.
- Nothing less than 10 minutes is a billable service.
- There are different code assignments allowed in the office setting (POS 11) versus hospital setting (POS 21/22) for CPT +99153
- +99153 is technical component (TC) only in hospital (POS 21/22); therefore, only the hospital may bill this code when performed in hospital setting.
- +99153 has an MUE of 9 which means up to 9 units may be billed.
- +99153 billable in OBL (POS 11), only has .33 PERVUs, and is payable by some carriers. Check individual carrier policies to determine coverage/reimbursement.
This code series requires the presence of an independent trained observer to assist in the monitoring of the patient’s consciousness and physiological status.
Independent Trained Observer: Healthcare professional who is qualified to monitor the patient during the procedure, who has no other duties (e.g., assisting at surgery) during the procedure.
Moderate Sedation Documentation Recommendations
- Document the total minutes of intraservice time in the report which supports practice management efficiencies.
- Example: “Conscious sedation was administered under the attending physician’s direction and continuous monitoring was performed by an independent trained (nurse specialist). Total monitored sedation time was 60 minutes. During the course of the procedure, the patient received 150 mg of intravenous fentanyl and 1 mg of midazolam.”
- If the time is documented and billed correctly, reimbursement should not be a problem with these codes, per carrier policy.
References: AMA 2023 CPT, CMS
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