Anesthesia Coding Alert

Question: BCBS Medicare Advantage is denying claims with 99152 and +99153, saying it's a non-covered service. I saw a document stating that this was true when the codes were originally released, but that it's supposed to be corrected in the next round of coding edits. Regular BCBS and regular Medicare both pay for the codes. Can you provide additional information, or do you have advice for how we should deal with these denials? Is there an alternate code we could report for conscious sedation services?

Illinois Subscriber

Answer: The correct answer depends partly on what type of service you're reporting in conjunction with the sedation.

According to 2017 CPT^® guidelines, moderate sedation codes should not be used to report the administration of medications for pain control, minimal sedation (anxiolysis), deep sedation, or monitored anesthesia care. This includes codes such as 99152 (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 age 5 years or older) and +99153 (... each additional 15 minutes intraservice time (List separately in addition to code for primary service).

If your provider administered sedation during a GI procedure, Medicare and Medicare Advantage direct you to report G0500 (Moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that 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 intra-service time; patient age 5 years or older [additional time may be reported with 99153, as appropriate]) as the base code/primary service instead of 99152. You can still add +99153 ad the add-on code for an adult patient.