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Coding Q&A: Moderate sedation update

12-13-2016 12:01

By Waleska Pabon-Ramos, MD, MPH  e-IRQ exclusiveTwitter link

Coding: Q Why was moderate sedation (MS) removed as an inherent service in procedures that are typically furnished using moderate sedation?

 In the past, the CPT Manual identified more than 400 diagnostic and therapeutic procedures that included moderate sedation as an inherent part of furnishing the service (codes identified with the bullseye, , also listed in Appendix G of the CPT Manual). Endoscopic procedures constituted a significant portion of these services.
CMS noted that anesthesia services were increasingly being reported separately for endoscopic procedures. Thus, practitioners providing endoscopic procedures were not performing the work of moderate sedation but were being reimbursed for that work, while payers were incurring duplicate payments.
As a result, moderate sedation has been removed from all procedures including moderate sedation as an inherent service. Most procedures reported by interventional radiologists fall into this category. Starting on Jan. 1, 2017, moderate sedation must be reported separately. This coding change allows for reimbursement of moderate sedation only when the service is furnished.

 

 What changes will be evident in the 2017 CPT Manual?

 The moderate sedation symbol (◎, bullseye) has been eliminated and the new CPT manual includes a blue triangle, , representing a revised code. Also, “Appendix G: Summary of CPT codes that include moderate (conscious) sedation,” has been removed. The new moderate sedation codes are discussed in pages 676–678 of the 2017 CPT Manual.

 

Coding: Q What codes should be reported when administering moderate sedation?

 Moderate sedation codes 99143–+99150 have been deleted. Moderate sedation should be reported with the following new codes:

 

Code

Descriptor

wRVU

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 patient’s level of consciousness and physiological status; initial 15 minutes of intraservice time, patient younger than 5 years of age

0.50

99152

… initial 15 minutes of intraservice time, patient age 5 years or older

0.25

+99153

… each additional 15 minutes intraservice time (List separately in addition to code for primary service)

0.00

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 intraservice time, patient younger than 5 years of age

1.90

99156

…initial 15 minutes of intraservice time, patient age 5 years or older

1.65

+99157

… each additional 15 minutes intraservice time (List separately in addition to code for primary service)

1.25

 

 What elements are used to determine the appropriate MS CPT code to be reported?

 Patient age, MS provider and MS intraservice time.

  1. Patient age: Codes 99151 and 99155 are the base codes (apply to the first 15 minutes) for moderate sedation services for patients younger than 5, while codes 99152 and 99156 are the base codes for patients age 5 or older. Codes 99153 and 99157 are add-on codes that can be reported with any of the base codes, regardless of patient age.
  2. MS provider: MS provided by the physician or health care professional performing the diagnostic or therapeutic service is reported with 99151–99153. In these cases, an independent trained observer is required. An independent trained observer is an individual qualified to monitor the patient during the procedure and who has no other duties during the procedure. The physician supervises and directs the independent trained observer. MS provided by a second physician other than the one performing the diagnostic or therapeutic service is reported with 99155–99157.
  3. MS intraservice time: Intraservice time for moderate sedation is not equivalent to procedural intraservice time. Intraservice time for moderate sedation is face-to-face time between the MS provider and the patient, while procedural intraservice time is skin-to-skin or needle-to-needle time. MS intraservice time starts when the first sedating agent(s) is administered. It ends when the procedure is completed, the patient is stable for recovery status, and the MS provider ends continuous face-to-face time with the patient. Please note that the MS provider must be present continuously from the start to the end of the MS intraservice time. MS intraservice time may be shorter or longer than procedural intraservice time. Time spent by the MS provider in the procedure room completing documentation after procedure completion, once the patient is stable for recovery, doesn’t constitute MS intraservice time. Also, if MS intraservice time ends, but the patient later requires more face-to-face time during the recovery period, the latter is not added to the MS intraservice time.

 

Coding: Q What elements must be documented to support reporting the new MS codes?

 Besides the elements described above, a statement declaring that moderate sedation was provided must be documented to attest that the MS codes are being reported for MS and not for the administration of medications for pain control, minimal sedation (anxiolysis), deep sedation or monitored anesthesia care (00100–01999).
Example statements to be included in the record documenting MS services:

  1. Dr. Jones, the physician performing the diagnostic/therapeutic procedure, provided XX minutes of moderate sedation services for this procedure with the assistance of an independent trained observer who had no other duties during the procedure.
  2. Dr. Smith, an independent provider, provided XX minutes of moderate sedation services for this procedure.

 

 With the new MS codes, who is the person required to administer the sedating agent(s) during the procedure?

 This is defined not by the MS codes but by individual organizations, states, etc. Frequently, when the MS provider also provides the diagnostic or therapeutic service, the MS provider orders the sedating agent(s), while the independent observer administers the sedating agents.

 

 With the new MS codes, do we have to report the sedating agents administered?

 The agents administered don’t determine whether MS was provided (vs. pain control, mild sedation, deep sedation). The CPT Manual states, “Moderate (also known as conscious) sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain cardiovascular function or a patent airway, and spontaneous ventilation is adequate.”

 

 How is moderate sedation reported if not administered in exact 15-minute increments?

 The answer to this question is complicated and comes in two parts:

  1. The base code(s) 99151, 99152, 99155 and 99156 require at least 10 minutes of sedation time to report this service.
  2. The add-on code(s) 99153 or 99157 require at least half of the listed time (>7.5 min) for the code to be reported.
  3. See examples below, in which we assume that the MS provider also provided the diagnostic or therapeutic service and the patient was an adult. A table is available on p. 678 of the 2017 CPT Manual.
    1. If MS intraservice time was 22 minutes, then MS would be reported with 99152.
    2. If MS intraservice time was 23 minutes, then MS would be reported with 99152 + 99153 x 1.
    3. If MS intraservice time was 37 minutes, then MS would be reported with 99152 + 99153 x 1.
    4. If MS intraservice time was 38 minutes, then MS would be reported with 99152 + 99153 x 2.
    5. If the MS intraservice time was 12 minutes, then MS would be reported with 99152.
    6. If the MS intraservice time was 9 minutes, then no MS service would be reported.

 

  Is MS reported the same way in the facility setting (e.g., hospital, outpatient hospital/ambulatory surgery center, skilled nursing facility) and nonfacility setting (e.g., physician office, freestanding imaging center)?

 When the MS provider also provides the diagnostic or therapeutic service, MS is reported using 99151–99153 in both settings. When the MS provider is a second physician other than the one performing the diagnostic or therapeutic service and services are provided in the facility setting, MS is reported using 99155–99157. When the MS provider is a second physician other than the one performing the diagnostic or therapeutic service and services are provided in the nonfacility setting, MS is not reported using 99155–99157.

 

  Since moderate sedation will be reported separately, did the wRVU of procedures that once included moderate sedation as an inherent service change?

 The procedural value decreased by 0.25 wRVUs to reflect removal of the value attributed to moderate sedation. For example, in the 2016 CPT code 37241 was valued at 9.00 wRVUs but in 2017 it will be valued at 8.75 wRVUs. The new MS codes must be reported in addition to the procedural codes to capture payment for moderate sedation services.
Also note that historically the moderate sedation codes (for reporting sedation when not inherent in a procedure code) demanded at least 30 minutes of sedation time to report these services. With the new changes to the definitions of the moderate sedation, a new 15-minute incremental standard has been established.


Read the addendum on erroneously bundled moderate sedation codes.

 

Disclaimer: SIR is providing this billing and coding guide for educational and information purposes only. It is not intended to provide legal, medical or any other kind of advice. The guide is meant to be an adjunct to the American Medical Association’s (AMA’s) Current Procedural Terminology (2015/CPT®). It is not comprehensive and does not replace CPT. Our intent is to assist physicians, business managers and coders. Therefore, a precise knowledge of the definitions of the CPT descriptors and the appropriate services associated with each code is mandatory for proper coding of physician service.

Every reasonable effort has been made to ensure the accuracy of this guide; but SIR and its employees, agents, officers and directors make no representation, warranty or guarantee that the information provided is error-free or that the use of this guide will prevent differences of opinion or disputes with payers. The publication is provided “as is” without warranty of any kind, either expressed or implied, including, but not limited to, implied warranties or merchantability and fitness for a particular purpose. The company will bear no responsibility or liability for the results or consequences of the use of this manual. The ultimate responsibility for correct use of the Medicare and AMA CPT billing coding system lies with the user. SIR assumes no liability, legal, financial or otherwise for physicians or other entities who utilize the information in this guide in a manner inconsistent with the coverage and payment policies of any payers, including but not limited to Medicare or any Medicare contractors, to which the physician or other entity has submitted claims for the reimbursement of services performed by the physician.

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