ED Coding and Reimbursement Alert

Question: Is it mandatory for the physician to be at the patient's bedside the entire time the patient is sedated to report moderate sedation services? What documentation do payers expect from the physician?


Florida Subscriber


Answer: If you are reporting sedation codes, the physician does need to be present during the sedation of the patient. In that case, the only time you can bill is the time the physician spends at the bedside.

CPT uses the term -intraservice time,- which it de-fines as follows: -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 physician's documentation should include three primary pieces of information:

1. the patient's age
2. whether the physician who is doing the sedation is also doing the procedure
3. the length of time the sedating physician spent with the patient (from the time he administered the drug until the time he could safely leave the patient in the nurse's care).