Anesthesia Coding Alert

Pay special attention to documentation terminology.

With new moderate sedation codes going into effect on Jan. 1, 2017, every coder needs a clear understanding of what constitutes moderate sedation is and what separates it from monitored anesthesia care (MAC) and general anesthesia.

Take note: Sedation services are not usually provided by the anesthesiologist, points out Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla. Per CPT^®, moderate sedation codes “are not used to report administration of medications for pain control, minimal sedation (anxiolysis), deep sedation or monitored anesthesia care (00100-01999). “Pain physicians may use moderate sedation for some of their services, though,” Dennis says.

CPT^® 2017 will add these codes for moderate sedation:

• 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).

Distinguish Between the Types

The question every coder must know how to answer when reporting any type of sedation service is, “How deep is ‘deep’?”

“If the sedation goes too deeply into sedation, it may actually border on MAC or even general as opposed to actual moderate sedation,” explains coding educator Leslie Johnson, CCS-P, CPC. “In moderate sedation, the patients are purposefully responsive and alert and don’t usually require additional intervention such as breathing assistance. It is in these deeper instances of sedation that become ‘anesthesia services’ and the codes from 00100-01999 are more appropriate for the service.”

Get Clues From the Documentation

As with any service, the provider’s documentation guides code choice. Johnson shares these tips for moderate sedation documentation.

• Documentation should be very similar to regular anesthesia services. Providers should indicate that someone is observing the patient during the procedure and that “someone” should sign the monitoring documents as well, noting the time the sedation begins and the time the sedation ends.
• Per CPT^® Assistant (February 2006), “Intraservice time starts with the administration of the sedation agent(s), requires continuous face-to-face attendance, and ends at the conclusion of personal contact by the physician providing the sedation.” The patient needs to be continuouslymonitored and reassessed just as if the patient were receiving anesthesia services.
• Documentation should also include the name of the procedure, medication names, dosages and routes of administration, who administered the medication(s) (physician or observer), notations of ongoing face-to-face assessments and vital signs monitoring. “The big difference between moderate sedation and anesthesia services will be, again, the level of depth of sedation,” Johnson says.
• Providers should indicate the level of depth of sedation with comments such as: “patient responds purposefully to commands” or “patient is alert throughout the procedure” or something similar. “Of course, if there are any complications or unexpected issues, such as a rise in blood pressure, should be documented as well,” Johnson says.  

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