Moderate (Conscious) Sedation Coding Guidelines

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Moderate (Conscious) 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 guidelines,
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
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Moderate (Conscious) Sedation Coding Guidelines

• Assessment of past medical and surgical history
  with an emphasis on cardiovascular, pulmonary,
  airway, or neurological conditions
• 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.

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Moderate (Conscious) Sedation Coding Guidelines

• 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
• 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.

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Moderate (Conscious) Sedation Coding Guidelines
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 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
• Simplifying Every Step of the Credentialing
  Process, we offer the most trusted and assured
  services for all you need, like Physician
  Credentialing Services, Group Credentialing
  Services, and Re-Credentialing Services.
  Additionally, We do provide
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• Chiropractic Credentialing Services
• Credentialing for Optometry Practice
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• Credentialing for Internal Medicine Practice
• Credentialing Services for Podiatry Practice
• Post-Service Work
• Once the continuous face-to-face time ends,
  additional face-to-face time cannot be added to
  the intra-service

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Moderate (Conscious) Sedation Coding Guidelines

• 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 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

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Moderate (Conscious) Sedation Coding Guidelines

• 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
• 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

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Moderate (Conscious) Sedation Coding Guidelines

• 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.
• 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.

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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
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

• 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 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).
  Its essential to use the correct codes to ensure
  accurate billing.

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Moderate (Conscious) Sedation Coding Guidelines

• 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.
• 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
  coding 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.