Wiki 99152 Proper Billing Guidelines PLEASE!

[Cpolisena]

Can someone PLEASE provide the proper guidelines in billing moderate sedation code 99152? Our Dr performs a heart cath. He does NOT push the sedation meds himself. The person who actually does push the meds, is NOT an employee within the same practice. He/She is an employee of the hospital. My interpretation is that my Dr can't bill for it period. He does not push the meds and the person that does is not employed by the same practice/group as my Dr. Can someone PLEASE confirm this for me and if possible, share a link to provide documentation to use that explains this better. I'm being told to bill this and I do not agree with it because we are technically not doing a single thing for the sedation. Other than being present in the room. Thank you in advance!!

 

[dwaldman]

Below I was not able to find an employee requirement to bill moderate sedation. I did see the below, listing the credentials/name of the trained observer from Palmetto Medicare. From CGS Medicare, they mention the physician does not have to inject the medication to report the codes in question.


https://engage.ahima.org/HigherLogi...tFileKey=9af2a07d-26e1-4694-b1de-a4c59d0dbc30

An independent trained observer whose sole duty is to monitor the patient’s level of consciousness and
physiological status must be present throughout the diagnostic or therapeutic service. The anesthesia note
must identify this person and his credentials (e.g., RN, NPP, PA).



https://www.cgsmedicare.com/parta/pubs/news/2017/03/cope2489.html

March 16, 2017
Updated: April 24, 2017

Clarification of CPT Code 99153
Code Descriptor: 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; each additional 15 minutes intraservice time (list separately in addition to code for primary service)

Billing for moderate sedation services (CPT Codes 99151 or 99152) represents the first 15 minutes of service. All physician work (as defined by AMA CPT: physician or qualified health care professional) occurs during that first 15 minutes. Please note: Physicians who are performing the procedure do NOT have to actually inject the drug, but MUST supervise and have face-to-face supervision at the time of the injection. Usually thereafter, the physician is engaged in performing the procedure, and a nurse will monitor the patient.

The CPT code 99153 represents additional time performed by the nurse (or other personnel). Since the nurse is employed by the facility, incident to billing is not appropriate. Therefore, CPT code 99153 is not payable to the physician since that nurse does not work for him/her, hence the PC/TC indicator 3. There is no physician work involved since he/she is engaged in performing the procedure and the nurse is not employed by the physician. Therefore, the physician cannot bill for the nurse’s services. In an office setting where the nurse is employed by the physician, the code will be billable and the practice will get the value of the facility side of the payment (ie. Practice expense and malpractice expense)

CMS has categorized the code with the PC/TC indicator 3 because it essentially behaves like a technical component only code, since there is no physician work.