Moderate Sedation Coding Guidelines

1. Moderate Sedation Coding Guidelines Medical Billers and Coders

2. Moderate sedation is services provided by the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports. They require the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status. The codes to report moderate sedation include all three components, the pre-service work, intra-service work, and the post-service work. But it is the intra-service 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.

3. 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; • 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: 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 prior to first sedating doses; and • IV access and fluids.

4. Intra-Service Work • Because it is the intra-service 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 the 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.

5. 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. • The following post-service work components are not included when determining the intra-service 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

6. 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 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 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

7. Update: The Centers for Medicare & Medicaid Services (CMS) determined that the moderate sedation work for certain gastro-intestinal (GI) endoscopy procedures differs from that of 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.

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9. 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. E.g. A patient undergoes a procedure 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 patient’s level of consciousness and physiologic status throughout the procedure. • Whether the patient is younger than five years of age; or five years old, or older. • The ‘intra-service time’ of the procedure. Intra-service time begins with the administration of the sedation agent and ends when the procedure is completed, the patient is stable for recovery status, and the provider performing the sedation ends personal continuous face-to-face time with the patient.