Anesthesia Coding Alert

Caveat: Have clear documentation that the codes apply.

CPT^® 2019 includes six codes for moderate sedation. They are divided into two code families based on who provides the sedation in relation to who performs the service.

If you find yourself reporting a case that allows you to report moderate sedation, your options are:

• 99151 (Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intraservice time, patient younger than 5 years of age)
• 99152 (… initial 15 minutes of intraservice time, patient age 5 years or older)
• +99153 (… each additional 15 minutes intraservice time (List separately in addition to code for primary service))
• 99155 (Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient younger than 5 years of age)
• 99156 (…  initial 15 minutes of intraservice time, patient age 5 years or older)
• +99157 (… each additional 15 minutes intraservice time (List separately in addition to code for primary service)).

Report add-on code +99153 in conjunction with 99151 and 99152, and add-on code +99157 with codes 99155 and 99156.