# Moderate Sedation



## nabernhardt (Oct 30, 2011)

I am needing some help please with how other facilities are coding and billing moderate sedation when performed by a CRNA.  And any resources would be helpful too.


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## nabernhardt (Nov 2, 2011)

I was going to try and put this out there again. What I am trying to find is when we do scopes such as EGD or Colonoscopy we bring our CRNAs in however they are filling out conscious sedation forms. In order to justify that we can code as anesthesia and bill out as anesthesia units they need to fill out an anesthesia form that meets MAC/DEEP sedation requirements. Same as when they are called into the ER. Does anyone have any suggestions or guidelines/resouces to help me.


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## debemrxs4@aol.com (Jun 17, 2019)

Hi. Need some help with moderate sedation. Our physicians do not normally do moderate sedation, however here and there they will, so when they actually perform moderate sedation on patients, do they have to actually dictate on the report that they injected it or that it was injected in their presence, OR can they just say the type of sedation it was and what time it began and ended OR does it have to be in the op note at all, can it just be in the patient's record somewhere, like in the nurse's notes? Just trying to cover all my basis here??? Thank you in advance


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## RDK720 (Jun 17, 2019)

debemrxs4@aol.com said:


> Hi. Need some help with moderate sedation. Our physicians do not normally do moderate sedation, however here and there they will, so when they actually perform moderate sedation on patients, do they have to actually dictate on the report that they injected it or that it was injected in their presence, OR can they just say the type of sedation it was and what time it began and ended OR does it have to be in the op note at all, can it just be in the patient's record somewhere, like in the nurse's notes? Just trying to cover all my basis here??? Thank you in advance



Here is a good resource. https://www.physicianspractice.com/coding/coding-moderate-sedation-different-2017

Moderate sedation is a separately reportable service when performed with procedures and CPT requirements are met. Moderate sedation is reported with CPT codes 99151-99157.
In order to report moderate sedation, documentation must include the following elements:
 The age of the patient
 The sedating agents administered
 The physician supervised the moderate sedation
 The total intraservice time of the moderate sedation (administration of sedating agent to completion of procedure)
 An independent, trained observer was present and monitored the patient throughout the procedure with no other duties performed
 The sedating agents administered


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## debemrxs4@aol.com (Jun 17, 2019)

RDK720 said:


> Here is a good resource. https://www.physicianspractice.com/coding/coding-moderate-sedation-different-2017
> 
> Moderate sedation is a separately reportable service when performed with procedures and CPT requirements are met. Moderate sedation is reported with CPT codes 99151-99157.
> In order to report moderate sedation, documentation must include the following elements:
> ...



Thank you so much, this has been very helpful!, Can you help me find where in the guidelines it states that the doctors have to document this information? I would like to have it to show them when I inform them, but I have not been able to find it in the moderate sedation/medicine section guidelines? Not sure if I'm looking in the right spot?


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## RDK720 (Jun 17, 2019)

debemrxs4@aol.com said:


> Thank you so much, this has been very helpful!, Can you help me find where in the guidelines it states that the doctors have to document this information? I would like to have it to show them when I inform them, but I have not been able to find it in the moderate sedation/medicine section guidelines? Not sure if I'm looking in the right spot?



Hi. We use Noridian which has a better explanation. Since I am not sure which state you are in, here is the guidelines from CMS https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3747CP.pdf

Here's Noridian's take on it.

FYI: Medicare only pays for 99152 and not 99153. BC bundles 99152 and 99153 with the procedure. 

Hope this helps.


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## LisaAlonso23 (Jul 14, 2019)

nabernhardt said:


> I am needing some help please with how other facilities are coding and billing moderate sedation when performed by a CRNA.  And any resources would be helpful too.



Moderate sedation would not be performed by an anesthesiologist or CRNA.  This article explains it best.



			https://www.aapc.com/blog/25598-draw-a-line-between-moderate-conscious-sedation-and-monitored-anesthesia-care/


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