Pulmonology Coding Alert

What you need to know about tracking intraservice work.

New moderate sedation codes have been effective since on Jan. 1, and unless you’re clear on what constitutes moderate sedation and what separates it from monitored anesthesia care (MAC) and general anesthesia, you could be making costly errors. And because these sedation services are not usually provided by the anesthesiologists, you’ll want to stay on top of the changes.

Know what qualifies as moderate sedation

“The big difference between moderate sedation and anesthesia services will be, again, the level of depth of sedation,” says coding educator Leslie Johnson, CCS-P, CPC. 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).”

“If the sedation goes too deeply into sedation, it may actually border on MAC or even general as opposed to actual moderate sedation,” explains Johnson. “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.”

So, what’s new in moderate sedation?

The new codes look similar to the prior codes. The three codes for each of these scenarios include one code for patients under age five, one for age five and over, and an add-on code for additional time providing moderate sedation.

Here are the codes you’ll use when your pulmonologist provides the moderate sedation herself for a procedure she’s performing:

• 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)
  ○Note: If the intraservice time is less than 10 minutes, you cannot report a moderate sedation.
• 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]).
  ○Note: Each subsequent increment used must be at least 8 minutes to justify billing an additional 99153 code.

Basically, you’ll now report separate codes for the procedure and for moderate sedation. The main change you’ll want to watch out for in the descriptors themselves relates to the sedation time itself.

Big change: In 2016, the primary codes all represented the first 30 minutes of intraservice time. The old add-on codes related to each additional 15 minutes, while in 2017 all the codes represent 15 minutes of intraservice time, not just the initial primary code.

Pay close attention to what qualifies as intraservice work

Intraservice time starts with administration of the sedation agents, requires continuous face-to-face attendance, and ends at the conclusion of personal contact by the physician providing sedation. However, you don’t need to actually administer the drug yourself: Other staff can inject the sedation drug at your direction when you are in the room.

Moderate sedation intraservice time includes the requisite, continuous face-to-face attention of the provider and monitoring of the patient’s response to the sedation, periodic reassessments, and vital signs including oxygenation, heart rate, and blood pressure.

Intraservice time is standard across all moderate sedation services, regardless of specialty. What’s required is that the physician “provide a checklist of information as described by the inclusion criteria” in order to bill for moderate sedation, advises Carol Pohlig BSN, RN, CPC, ACS,  senior coding and education specialist at the Hospital of the University of Pennsylvania.

Stop the clock: The moderate sedation intraservice time ends when the procedure is completed, the patient is stable, and the provider providing sedation ends personal face-to-face care of the patient.

…and what does not qualify as intraservice work

The new CPT^® guidelines include a list of pre- and post-work components that are not included in intraservice time.

Pre-service work components not included:

• A thorough screening history involving assessment of the patient’s past medical and surgical history with particular emphasis on cardiovascular, pulmonary, airway, or neurological conditions, review of the patient’s previous experience with anesthesia or sedation and any family history of sedation complications, summary of the patient’s present medication list and any drug allergy and intolerance history.
• A physical exam including focused emphasis on the mouth, jaw, oropharynx and airway for Mallampati score assessment, chest, lungs, heart and circulation, vital signs includi-ng oxygenation with end tidal C02 when indicated.
• A review of any pre-sedation diagnostic tests, completion of a sedation assessment form and obtaining informed consent.
• Starting IV access and fluids to maintain patency.

The following post-service work components are not included:

• Assessment of the patient’s vital signs, level of consciousness, neurological, cardiovascular and pulmonary stability in the post-sedation recovery period.
• Assessment of the patient’s readiness for discharge.
• Documenting the sedation service.
• Communicating to family members or caregivers regarding the sedation service.

4 Things You Need to Document

With that extensive list of what’s not allowed, your documentation should be specific about these four areas to ensure that claims aren’t denied:

• Physician/patient face-to-face sedation start time, face-to-face sedation stop time, and total moderate sedation time in minutes
• 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 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.  
• Attestation that patient was monitored continuously 1:1 throughout the entire procedure by the physician while sedation was administered. Providers should indicate that someone is observing the patient during the procedure and that “someone” should sign the monitoring documentsas well, noting the time the sedation begins and the time the sedation ends.

Old way/New way: “Documentation was required for this service when the payment was bundled into the procedure payment,” says Pohlig. “Now that it is separately reported, you still have to maintain all of the JCAHO and facility-required documentation for moderate sedation. This same information can be used to support the details for billing.”