Moderate Sedation Coding

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Moderate Sedation Coding
Moderate Sedation A drug-induced depression of
consciousness during which patients respond
purposefully to verbal commands, either alone or
amid by light tactile stimulation. Moderate
Sedation also referred as conscious sedation, is
a drug-induced depression of consciousness. A
patient who has been sedated in this way is
relaxed and customarily insensitive to pain, but
remains awake and ready to reply to verbal
instruction. If medically necessary and properly
documented, moderate sedation is a service that
is separately reported. Three primary factors
for moderate sedation to code Different
Provider Administration Whether the similar
provider is both administering the sedation and
performing the procedure that the sedation is
required. Coding changes when a distinct provider
administers the sedation. If a special provider,
aside from the provider performing the primary
procedure, administers the moderate sedation, an
independent observer isnt required.
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Moderate Sedation Coding
Patient Age Whether the patient is younger than
five years of age or five years old, or
older. Intraservice Time The intraservice
time of the procedure. Intraservice time begins
with the administration of the sedation agent,
and ends when the procedure is completed, the
patient is stable for recovery status, and also
the provider performing the sedation ends
personal continuous face-to-face time with the
patient. Per CPT Assistant (May 2017), the time
spent on postservice activities that are required
for moderate sedation arent included when
calculating time and selecting the appropriate
moderate sedation codes. The CPT codebook
includes a helpful chart to determine the proper
number of units of moderate sedation to report,
based on intraservice time. CPT Codes for
Moderate Sedation The six code you will us to
report moderate sedation, with full descriptors,
are as follows
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Moderate Sedation Coding
Code 99151 Moderate sedation services provided
by the same physician or other qualified
healthcare professional performing the diagnostic
or therapeutic service that the sedation
supports, requiring the presence of an
independent trained observer to help within the
monitoring of the patients level of
consciousness and physiological status initial
15 minutes of intraservice time, patient younger
than 5 years of age Code 99152 initial 15
minutes of intraservice time, patient age 5 years
or older Code 99153 Moderate sedation services
provided by the same physician or other qualified
healthcare 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 intraservice time (list
separately in addition to code for primary
service)
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Moderate Sedation Coding
Code 99155 Moderate sedation services provided
by a physician or other qualified healthcare
professional other than the physician or other
qualified healthcare professional performing the
diagnostic or therapeutic service that the
sedation supports initial 15 minutes of
intraservice time, patient younger than 5 years
of age Code 99156 initial 15 minutes of
intraservice time, patient age 5 years or
older Code 99157 Moderate sedation services
provided by a physician or other qualified
healthcare 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 intraservice time (List separately in
addition to code for primary service)
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Moderate Sedation Coding
Can Physician bill for the Moderate sedation
service? Moderate sedation is a part B covered
service, with administration by the physician
performing the procedure. Moderate sedation is
not a hospital outpatient or ASC clinical staff
service, so the coding/billing is completed by
doctor as a professional fee. It is the physician
associated with moderate sedation. The registered
nurse under supervision may push the drugs but
that person's cost is an element of facility
fee. Are you trying to find any assistance
in Medical Billing and Coding? Reach out to us
today at 888-357-3226 or info_at_medicalbillersandcod
ers.com.