ED Coding and Reimbursement Alert

Question: In our ED group, our moderate sedations are usually less than 16 minutes. The CPT Assistant® Oct 2011 issue states that if the moderate sedation is less than 16 minutes, it is not separately billable. Is that correct?

Wisconsin Subscriber

Answer: The October 2011 CPT Assistant® reference comes from a Commonly Asked Questions Section asking if it is appropriate to report the moderate sedation codes for the first 30 minutes of Intraservice time if only 10 minutes of moderate sedation are provided. The answer given was no.

The rationale offered was that moderate sedation codes are time based and the CPT® descriptors for the base codes (99143, 99144, 99148 and 99149) specifically mention 30 minutes of intra-service time. Intra-service time is defined in the moderate sedation preamble to begin with the administration of the sedation agent, requiring continuous face to face attendance, and ending when that personal contact concludes.

If the period of moderate sedation intra-service time extends past 30 minutes, add on codes (99145 and 99150) are available to capture the additional work involved. Although pre- and post-service times associated with moderate sedation are included in assignment of its value, for reporting purposes only the intra-service time can be counted. The Assistant further specifies that, "A unit of time is attained when the midpoint is passed. Therefore, in order to report a code with a unit time of 30 minutes, 16 minutes or more of the service described must be provided." In other words, you must exceed the midpoint to qualify.

New language in the CPT® Introduction for 2011 clarified that the minimum time thresholds needed to report a time based code. The CPT® code set contains many codes with a time basis for code selection. Basically it says that unless there are individual code or range specific instructions to the contrary, a unit of time is attained when the mid-point is passed.

In a recent straw poll of experienced ED providers, most sedation did involve less than 16 minutes of intra-service time. Longer sedations often involved complex laceration repairs, frequently with the sedation performed by the ED physician in support of another specialist such as a pediatric or plastic surgeon.