Coding for Moderate Sedation is Different in 2017

Moderate (or conscious) sedation is a drug-induced depression of consciousness, which may be provided during colonoscopy, cataract removal, or dental procedures, for example. The patient becomes relaxed and insensitive to pain, but remains awake and able to respond to verbal instruction.

In previous years, the American Medical Association (which produces the CPT codebook) and CMS disallowed separate reporting of moderate sedation in many circumstances. Nearly 450 CPT codes were valued to include moderate sedation when performed.

As of Jan. 1, 2017, CPT no longer defines moderate sedation as an inherent part of any procedure. Moderate sedation, when performed and properly documented, now may be reported separately. Per the 2017 Physician Fee Schedule Final Rule, "This coding change [provides] for payment for moderate sedation services only in cases where it is furnished."

Prior codes to describe moderate sedation (99143-99150) are deleted and replaced by six new codes that are assigned according to: who performs the moderate sedation (the same provider who performs the primary service, or another provider); patient age (5 years or younger, or older than 5 years); and, intraservice time of the moderate sedation.

Tip: CPT defines intraservice time as beginning with the administration of the sedation agent,and ending 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. Additional qualifications may be found in the Moderate Sedation portion of the CPT manual.

Same provider performs both the primary procedure and the moderate sedation:

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 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"

99152 "…initial 15 minutes of intraservice time, patient age 5 years or older"

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 patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (list separately in addition to code for primary service)"

If the same provider performs both the primary procedure and the moderate sedation that provider should bill for the moderate sedation; however, there must be a trained observer to assist. "CPT® Changes 2017: An Insider's View" provides a clinical example:

"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."

In this case, suppose the patient is older than 5 years, and the intraservice time for the moderate sedation is 33 minutes. Proper reporting for the moderate sedation is 99152 (minutes 1-15) and 99153 (minutes 16-30). Per CPT guidelines, the minimum time requirement to report moderate sedation is 10 minutes, and at least seven minutes must pass to report an additional unit; therefore, minutes 31-33 are not reported.

If the circumstances were the same, but the patient is younger than 5 years, proper reporting is 99151 (first 15 minutes), 99153 (minutes 16-30).

Different provider performs primary procedure and moderate sedation:

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"

99156 "… initial 15 minutes of intraservice time, patient age 5 years or older"

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)"

In these cases, the provider performing the moderate sedation - not the provider performing the primary procedure - bills the moderate sedation. No independent observer is necessary to monitor the patient. In other respects, reporting is the same as when using 99151-99153.

For example, a 4-year-old patient undergoes a procedure necessitating moderate sedation. Separate providers perform the primary procedure and moderate sedation. The intraservice time is 39 minutes. Proper reporting is 99155 (first 15 minutes of intraservice time for a patient 5 years old or younger) and 99157 x 2. The first unit of 99157 reports minutes 16-30. The second unit of 99157 reports minutes 31-39.

Tip: The CPT manual includes a chart to help you determine the proper number of units of moderate sedation to report, based on intraservice time.

Medicare Designates G Code for Moderate Sedation with Certain GI Endoscopy Services

CMS determined that the moderate sedation work for certain esophageal dilation, biliary endoscopy, and endoscopic retrograde cholangiopancreatography (ERCP) procedures differs from that of other endoscopy procedures. For this reason, CMS augments the new moderate sedation CPT codes with a gastro-intestinal (GI) endoscopy-specific moderate sedation code, G0500 (Moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that 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 intra-service time; patient age 5 years or older). You should report G0500 instead of CPT 99151-99152 when reporting moderate sedation to Medicare patients in addition to designated GI endoscopy services. For additional details and a full list of designated GI endoscopy services, see Table 26 of the 2017 Medicare Physician Fee Schedule Final Rule.

When reporting G0500 to Medicare, additional time beyond the initial 15 minutes of intraservice time may be reported using 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 patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service), as appropriate.