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Hello,
I work for an Non Profit Outpatient Hospital that owns physician practices (OPPS - Method 1).
Coding captures MCS (Moderate Conscious Sedation) professional fees for our employed General Surgery Providers for Colonoscopies, Endoscopies, etc.
We work with a third party coding vendor to capture our professional charges, and they are suggesting a documentation improvement.
Our providers are currently listing the Assistant RN or Independent Trained Observer, the sedation medications with Start and Stop Times, and this statement "the patient was monitored throughout for IV conscious sedation to include oximetry, telemetry, and blood pressure monitoring", along with all other expected documentation requirements for these procedures.
The coding vendor wants us to add that the Provider was watching the RN or Observer who was watching the patient. Essentially " I personally supervised the assisting RN or observer who monitored the patient throughout for IV conscious sedation to include oximetry, telemetry, and blood pressure monitoring".
Our team is looking for exact CMS or AMA guidelines outlining this above outlined specificity, and any additional feedback.
Thank you!
I work for an Non Profit Outpatient Hospital that owns physician practices (OPPS - Method 1).
Coding captures MCS (Moderate Conscious Sedation) professional fees for our employed General Surgery Providers for Colonoscopies, Endoscopies, etc.
We work with a third party coding vendor to capture our professional charges, and they are suggesting a documentation improvement.
Our providers are currently listing the Assistant RN or Independent Trained Observer, the sedation medications with Start and Stop Times, and this statement "the patient was monitored throughout for IV conscious sedation to include oximetry, telemetry, and blood pressure monitoring", along with all other expected documentation requirements for these procedures.
The coding vendor wants us to add that the Provider was watching the RN or Observer who was watching the patient. Essentially " I personally supervised the assisting RN or observer who monitored the patient throughout for IV conscious sedation to include oximetry, telemetry, and blood pressure monitoring".
Our team is looking for exact CMS or AMA guidelines outlining this above outlined specificity, and any additional feedback.
Thank you!