Moderate (Conscious) Sedation Coding Guidelines

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Moderate (Conscious) Sedation Coding Guidelines

• Moderate Sedation Coding Guidelines
• To ensure accurate billing, its essential to
  follow Sedation Coding Guidelines, which specify
  the proper codes for different sedation levels
  and procedures. By adhering to these challenges,
  medical practices can avoid coding errors and
  ensure appropriate reimbursement.
• Moderate sedation is a service provided by the
  physician or other qualified healthcare
  professional performing the diagnostic or
  therapeutic service that the sedation supports.
  It requires the presence of an independent
  trained observer to assist in monitoring the
  patients level of consciousness and
  physiological status.
• The codes to report moderate sedation include all
  three components pre-service, intra-service, and
  post-service.  However, the intra-service work
  drives the selection of codes by time.  Below is
  a summary of what constitutes each component as
  defined by CPT.
• Pre-Service Work
• The following pre-service work components are not
  included when determining the intra-service time
• Assessment of past medical and surgical history
  with an emphasis on cardiovascular, pulmonary,
  airway, or neurological conditions

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Moderate (Conscious) Sedation Coding Guidelines

• Review of the patients previous experiences with
  anesthesia and/or sedation and family history of
  sedation complications
• Summary of the patients present medication list
• Drug allergy and intolerance history
• Focused physical exam with emphasis on mouth,
  jaw, oropharynx, neck, and airway for Mallampati
  score assessment chest and lungs and 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 before first
  sedating doses and
• IV access and fluids.
• Intra-Service Work
• Because it is the intra-service time (only) that
  is used to determine the appropriate moderate
  sedation CPT code(s), you must be aware of how
  CPT defines it

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Moderate (Conscious) Sedation Coding Guidelines

• Begins with the administration of the sedating
  agent(s)
• Ends when the procedure is completed, the patient
  is stable in 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 healthcare
  professional
• Requires monitoring of patient response to the
  sedating agents
• If you are performing the procedure, you will be
  required to supervise and direct an independent
  trained observer who will assist in monitoring
  the patients level of consciousness and
  physiological status throughout the procedure.
• Stuck on medical billing? Know what challenges in
  Credentialing, Charge Entry, Payment Posting,
  Benefits/Eligibility Verification, Prior
  Authorization, Filing claims, AR Follow-Ups, Old
  AR, Claim Denials, and resubmitting rejections
  with Medical Billing Companies  Medical Billers
  and Coders.
• Following Sedation Coding Guidelines is crucial
  for accurate billing and compliance in medical
  practices. These guidelines help define the
  correct codes for varying levels of sedation,
  ranging from minimal to deep

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Moderate (Conscious) Sedation Coding Guidelines
sedation. Coders who adhere to Sedation Coding
Guidelines reduce the risk of claim denials and
audits due to incorrect coding or documentation.
This can help ensure medical facilities receive
proper reimbursement for their sedation
services. Medical Billers and Coders, a leading
medical billing company, understands the
importance of Sedation Coding Guidelines and has
a team of experts dedicated to applying them
correctly. By following Sedation Coding
Guidelines, MBC ensures that the billing process
is smooth and efficient, allowing healthcare
providers to focus on patient care. When
practices use the correct codes outlined in
Sedation Coding Guidelines, they can avoid costly
billing mistakes and streamline their revenue
cycle management.
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Moderate (Conscious) Sedation Coding Guidelines

• Credentialing Services
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• Post-Service Work
• Once the continuous face-to-face time ends,
  additional face-to-face time cannot be added to
  the intra-service time. However, it is part of
  the post-service work.

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Moderate (Conscious) Sedation Coding Guidelines

• The following post-service work components are
  not included when determining the intra-service
  time for reporting
• Assessment of the patients vital signs, level of
  consciousness, neurological, cardiovascular, and
  pulmonary stability in the post-sedation recovery
  period
• Evaluation of the patients readiness for
  discharge
• Preparation of the documentation
• Communication with the family/caregiver regarding
  the sedation
• Documentation
• The intra-service time is the only time that can
  be counted to determine the assignment of the CPT
  code(s)
• CPT has defined the intra-service 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 would be best if you used 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 none of this time can be calculated to
  determine code selection

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Moderate (Conscious) Sedation Coding Guidelines

• Because having a trained independent observer is
  required to be sure to include this information
  in your documentation
• Do not include any of the pre-service and
  post-service work when calculating the
  intra-service time
• CPT Codes
• Codes for moderate sedation are chosen and
  assigned based on three primary factors
• Whether the same provider is both administering
  the sedation and performing the procedure for
  which the sedation is required. Coding changes
  when a different provider administers the
  sedation. For example, a patient undergoes a
  method that requires moderate sedation. The
  treating physician will perform both the
  supported procedure and the moderate sedation
  service. The physician will supervise and direct
  an independent, trained observer who will assist
  in monitoring the patients level of
  consciousness and physiologic status throughout
  the procedure. If a different provider, other
  than the provider performing the primary method,
  administers moderate sedation, an independent
  observer is not required.
• Whether the patient is younger than five years of
  age, five years old, or older.
• The procedures intra-service time begins with
  administering the sedation agent and ends when
  the procedure is completed, the patient is stable
  in recovery status, and the provider performing
  the sedation ends personal continuous
  face-to-face time with the patient.

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Moderate (Conscious) Sedation Coding Guidelines
Total Intra-service Time Patient age CPT Code(s)Same physician performing procedure CPT Code(s)Different physician who is performing a procedure
Less than 10 minutes Any Age Not reported separately Not reported separately
10-22 minutes  lt 5 years 99151 99155
10-22 minutes Five years or older 99152 99156
23-37 minutes lt 5 years 99151 99153 x1 99155 99157 x1
23-37 minutes Five years or older 99152 99153 x1 99156 99157 x1
38-52 minutes lt 5 years 99151 99153 x2 99155 99157 x2
38-52 minutes Five years or older 99152 99153 x2 99156 99157 x2
53-67 minutes lt 5 years 99151 99153 x3 99155 99157 x3
53-67 minutes Five years or older 99152 99153 x3 99156 99157 x3
68-82 minutes lt 5 years 99151 99153 x4 99155 99157 x4
68-82 minutes Five years or older 99152 99153 x4 99156 99157 x4
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Moderate (Conscious) Sedation Coding Guidelines
CPT CODE DESCRIPTION
MODERATE SEDATION PERFORMED BY THE SAME PROVIDER MODERATE SEDATION PERFORMED BY THE SAME PROVIDER
99151 Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patients level of consciousness and physiological status initial 15 minutes of intra-service time, patient younger than five years of age
99152 Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patients level of consciousness and physiological status initial 15 minutes of intra-service time, patient age five years or older
99153 Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patients level of consciousness and physiological status each additional 15 minutes of intra-service time
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Moderate (Conscious) Sedation Coding Guidelines
CPT CODE DESCRIPTION
MODERATE SEDATION PERFORMED BY ANOTHER PROVIDER MODERATE SEDATION PERFORMED BY ANOTHER PROVIDER
99155 Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports initial 15 minutes of intra-service time, patient younger than five years of age
99156 Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports initial 15 minutes of intra-service time, patient age five years or older
99157 Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports each additional 15 minutes of intra-service time
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Moderate (Conscious) Sedation Coding Guidelines
CPT CODE DESCRIPTION
MODERATE SEDATION PERFORMED BY ANOTHER PROVIDER MODERATE SEDATION PERFORMED BY ANOTHER PROVIDER
99155 Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports initial 15 minutes of intra-service time, patient younger than five years of age
99156 Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports initial 15 minutes of intra-service time, patient age five years or older
99157 Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports each additional 15 minutes of intra-service time
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Moderate (Conscious) Sedation Coding Guidelines

• Update
• The Centers for Medicare Medicaid Services
  (CMS) determined that the moderate sedation work
  for particular gastrointestinal (GI) endoscopy
  procedures differs from other endoscopy
  procedures. You should report G0500 instead of
  99151-99152 when reporting moderate sedation to
  Medicare patients in addition to designated GI
  endoscopy services. You can find a list of
  designated GI endoscopy codes here. When
  reporting G0500, you may report additional time
  beyond the initial 15 minutes of intra-service
  time using 99153.
• FAQs
• What is moderate (conscious) sedation?
• Moderate sedation, or conscious sedation, is when
  the patient remains conscious and responsive but
  is relaxed and free from pain during medical
  procedures.
• What are the 4 levels of sedation?
• Minimal Sedation Patients are relaxed but fully
  awake and responsive. They can maintain their own
  airway and communicate effectively.
• Moderate Sedation Patients are drowsy but can
  respond to verbal commands or light stimulation.
  Airway maintenance is usually not a concern.

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Moderate (Conscious) Sedation Coding Guidelines

• Deep Sedation Patients are not easily arousable
  and may need assistance with airway maintenance.
  They might not respond to verbal commands but can
  be roused with repeated stimulation.
• General Anesthesia Patients are completely
  unconscious and unresponsive. Airway support and
  controlled ventilation are required.
• What are the critical coding guidelines for
  moderate (conscious) sedation?
• The coding guidelines for moderate sedation
  typically include specific CPT (Current
  Procedural Terminology) codes that indicate the
  level of sedation, duration, and who administers
  it (physician or other healthcare professional).
  Using the correct codes is essential to ensure
  accurate billing.
• When is it appropriate to use moderate sedation
  codes?
• Moderate sedation codes are used when sedation is
  administered to a patient during a procedure,
  such as minor surgeries or diagnostic tests,
  where the patient needs to be relaxed but not
  entirely unconscious.
• What documentation is required to support
  moderate sedation coding?
• Documentation should include details of the
  sedation procedure, such as the dosage and type
  of sedation used, the duration, the medical staff
  involved, and the patients response during and
  after the procedure. Accurate documentation is
  critical to billing correctly and avoiding claim
  denials.

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Moderate (Conscious) Sedation Coding Guidelines

• How can Medical Billers and Coders help with
  moderate sedation coding?
• Medical Billers and Coders (MBC) specializes in
  Medical Billing and Coding, including moderate
  sedation. MBCs experts ensure compliance with
  guidelines and help healthcare providers avoid
  billing errors, reducing the risk of audits and
  claim rejections. They can also assist with
  training and best practices in sedation coding.