Anesthesia Coding Alert

Get clear on everyone’s role in the procedure.

CPT^® includes several codes for moderate (conscious) sedation, which providers and coders sometimes confuse with the services listed in the Anesthesia section. Read through our refresher on what moderate sedation is – and isn’t – and you’ll be sure to handle these cases with ease.

Myth 1: Anesthesiologists Provide Moderate Sedation

The section of moderate sedation codes in CPT^® was completely reworked a number of years ago. According to the American Society of Anesthesiologists (ASA), “It is important to note that anesthesiologists provide anesthesia (0XXXX codes) services. The Moderate Sedation codes were developed for cases where non-anesthesiologist physicians sedate patients.”

What it means: When you’re coding for a provider who administers anesthesia during a standard procedure, you choose from the Anesthesia section codes (00100-01999), says Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla. However, when an anesthesia provider performs a nerve block or injection for therapeutic purposes, he or she is classified as a “surgeon.” If your physician administers moderate sedation before performing an injection or other “surgical” service, you can report the appropriate moderate sedation code with the procedure code.

Myth 2: A Provider Can Monitor the Sedation He Administers

All moderate sedation codes include verbiage stating that the sedation requires “the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status.” The performing physician (or CRNA) cannot safely sedate, monitor the patient, and perform the procedure or test.

Observer: The healthcare professional who serves as the “independent trained observer” has no other responsibilities than to monitor the patient, administer drugs, and record what transpires. This trained observer must have BLS (Basic Life Support) and/or ACLS (Advanced Cardiac Life Support) certification.

Myth 3: All Sedation Is the Same

The ASA outlines four levels of sedation: minimal, moderate, deep, and general anesthesia.

Moderate sedation is defined as: Drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. Patient maintains the ability to maintain his or her airway independently.

Based on this definition, moderate sedation does not include minimal sedation (which alters cognition but still allows the patient to have airway control and respond to verbal stimulation) or deep sedation (during which the patient is not able to respond to verbal or light tactile stimulation and may not be able to maintain his own airway).

Each of these types of sedation is lower on the continuum than general anesthesia.

Myth 4: The Level of Sedation Remains the Same Throughout the Case

It is not always possible to predict how an individual patient will respond to sedation. During cases involving moderate sedation, the trained observer and physician/CRNA will work together to determine the appropriate level of sedation. They should always keep in mind that:

• A single sedative cannot reliably achieve the same level of sedation for all patients
• Moderate sedation can quickly and unpredictably become deep sedation or general anesthesia
• Each provider needs to be equally vigilant regarding the patient’s status at all times, no matter the patient’s age or level of sedation.

Myth 5: Any Service Can Qualify for Moderate Sedation

Some procedures include the work accomplished by moderate sedation, such as 22526 (Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level) and +22527 (…1 or more additional levels (List separately in addition to code for primary procedure).

Tip: Codes in the CPT^® manual that include a “bull’s eye” symbol represent services that cannot be reported with a separate moderate sedation code. You can find a full list of these procedures in Appendix G of CPT^®.