Anesthesia Coding Alert

Keep 4 things in mind when deciding whether you can report the service.

Hearing multiple terms for different levels of anesthesia administration, including moderate sedation, is not uncommon. CPT^® 2019 includes several codes for moderate sedation, which providers and coders sometimes confuse with the services listed in the Anesthesia section. If you’ve fallen in that trap, help is here: Read through our refresher on what moderate sedation is – and isn’t – so you can handle these cases with ease.

Reminder 1: Anesthesiologists Don’t Often Provide Moderate Sedation

The section of moderate sedation codes in CPT^® was completely reworked in 2017, with codes you had known of for years being deleted and replaced by a new code family. See the sidebar “Choose from These Codes When Reporting Moderate Sedation,” on page XX for the codes and their descriptors.

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), reminds Kelly Dennis, MBA, ACS-AN, CAN-PC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fl. However, when an anesthesia provider performs a nerve block or injection for therapeutic purposes, he 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.

“Moderate sedation services are often provided by pain management physicians,” Dennis says. “It is rare to see an anesthesia provider who reports moderate sedation codes as they are directed in the CPT^® Moderate (Conscious) Sedation to ‘report administration of medications for pain control, minimal sedation (anxiolysis), deep sedation or monitored anesthesia care’ under the ASA code section. However, it’s still wise to be aware of the moderate sedation codes and their usage.”

Reminder 2: Providers Cannot Administer and Monitor Sedation

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, certified registered nurse anesthetist) 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 Basic Life Support (BLS) and/or Advanced Cardiac Life Support (ACLS) certification.

Reminder 3: Moderate Sedation Is Not a Catch-All Term

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 a patient 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.

Reminder 4: Sedation Levels Can Change

Predicting how an individual patient will respond to sedation is not always possible. 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 always needs to be equally vigilant regarding the patient’s status, no matter the patient’s age or level of sedation.

“Remember that if a case changes from monitored anesthesia care (MAC) to general anesthesia, medical direction criteria should be documented in an anesthesia care team environment that reports medical direction services,” Dennis says.