# Documentation necessary for billing Moderate sedation in the Cath Lab.



## nellt (Feb 21, 2017)

What documentation is necessary for billing Moderate Sedation in the Cath Lab?
In physician billing does the documentation (time) for the moderate sedation need to be in the body of the note or can you code from the procedure listed at the beginning of the note and the nurse notes?
Thanks in advance for your help


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## lisabatts79 (Feb 22, 2017)

I bill from op report.  Physician documents start/end time.  They use military time so please become familiar with that.  I have experience with military time so I did not have to learn how to do that.  
Sincerely, Lisa Jo Batts, CPC, CMBS


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## Margaret Morgan (Feb 22, 2017)

Be sure the physician signs off on the nurses notes if you use them.  Remember the drug and dosage must be in the record, either the physician report or physician signed nurses notes.  If the physician is directing the nurse, her/his name should also be in the record.  I require the start and stop time over total time due to past experience with time based codes and Medicare, although I haven't found it to be a clearly stated requirement. I hope my experiences can help you.
Margaret


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## nellt (Feb 22, 2017)

*Thanks so much*

Thanks for your input. Really appreciated.


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## AlisiaJ (Oct 3, 2017)

*Moderate sedation Documentation guidelines*

Hi there,

I was hoping and wondering if there is anyone whom would have and be able to share some good resources for Moderate sedation and the documentation guidelines.  What is required to be reported and is there a list of codes this can be reported with? 


Thank you in advance for your help!


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