Anesthesia Coding Alert

Question: Our physicians do not normally use moderate sedation, so I’m not accustomed to reporting those codes. When they do perform moderate sedation, do they have to actually dictate on the report that they injected the anesthetic or that it was injected in their presence, or can they simply list the type of injection and times for induction and ending? Does a notation about moderate sedation need to be in the operative record at all if it’s documented in the patient’s record?

Arizona Subscriber

Answer: Moderate sedation is a separately reportable service when performed with procedures and CPT^® requirements are met. Moderate sedation is reported with the most appropriate choice from CPT^® codes 99151-+99157:

• 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).

In order to report moderate sedation, documentation must include the following elements:

• The age of the patient
• The sedating agents administered
• The physician supervised the moderate sedation
• The total intraservice time of the moderate sedation (administration of sedating agent to completion of procedure)
• An independent, trained observer was present and monitored the patient throughout the procedure with no other duties performed
• The sedating agents administered.

Remember that some insurers only reimburse for certain moderate sedation codes. For example, Medicare only pays for 99152 and not +99153. Blue Cross bundles 99152 and +99153 with the procedure.