# Locations of Documentation for Moderate Sedation 99152/99153



## jtuominen (Jan 23, 2017)

Looking for some general consensus here, please as many answers as possible--
Where are people pulling the information from to bill moderate sedation codes?
Operative note or cath lab procedure log, or both?


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## cgaston (Jan 24, 2017)

In order to bill the new codes the surgeon needs to note that he/she not only administered the anesthesia but also the length of the administration. So I look for that information in the operative note.


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## jtuominen (Jan 24, 2017)

Thanks. If the MD has to be the one to push the meds, hmm that would really limit the scenarios this code set could be billed. Ill have to think about that with my practice.
Im pretty sure in the instances that would qualify for lets say 99152 and 99153, I think the doc would be ordering the pushes and they would be administered by the RN.


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## cgaston (Jan 24, 2017)

If the RN is a CRNA then the Anesthesia group would bill for the anesthesia service.

These codes are only to be billed if the Surgeon (or someone in the Surgeon's group for the second set of codes) is administering the anesthesia. If anyone outside of your billing group is administering the sedation then THEY will bill for the service and the Surgeon only bills for the surgical portion just like they have in the past.


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## jtuominen (Jan 24, 2017)

My scenario is a CV Lab physician directing a hospital nurse as an independent trained observer, who is physically pushing the meds with each order given by doctor.


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## Jim Pawloski (Jan 25, 2017)

jtuominen said:


> My scenario is a CV Lab physician directing a hospital nurse as an independent trained observer, who is physically pushing the meds with each order given by doctor.



In your case, the sedation codes can be used, because the doctor is telling the nurse who is monitoring the patient to give sedation.
HTH,
Jim Pawloski, CIRCC


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## ChrisZim (Jan 30, 2017)

​


cgaston said:


> In order to bill the new codes the surgeon needs to note that he/she not only administered the anesthesia but also the length of the administration. So I look for that information in the operative note.



I disagree about the "administering" - more like being the one responsible for the administration/supervision of the sedation - I think a nurse can do the injection.  My understanding is that the requirement is that the provider billing be the one a) supervising/overseeing the sedation b) must be present face:face (1:1) with the patient during the time billed but he can have someone else inject it.  See the following http://aabronchology.org/2017/01/06/coding-and-billing-change-alert-moderate-sedation-for-pulmonary-procedures/​


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## Marybeth (Mar 21, 2017)

*99152/99153*

So, I am inclined to agree that the codes cannot be billed unless the op/cath note documents what was given, when it was given, how it was given, who gave it and that it was supervised/order by the physician.  This makes total sense to me.  

Is this a correct statement?


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