Hello,
I would like to ask for interpretation of the guidelines for MCS. We are having an ongoing debate as to what has to be included in the documentation before MCS is coded and billed. My understanding is that all three components preservice work, intraservice work, and postservice work has to be in the chart as proof all elements are met. I do know the pre and postservice are not reported separately, and not included in the intraservice time; only intraservice time counts from administration of the first sedative and ending when the procedure ends, the patient is ready for recovery, and face-to-face time ends.
The guidelines under preservice work indicate: The preservice activities required for moderate sedation are included in the work described by each of these codes 99151-99157. Is this an all components for pre, intra, and postservice should be accessible to the coder, if not sedation is not coded? The debate is if it really is the responsibility of the coder to ensure the work has been done, or are they allowed to code the intraservice work, without the pre-and post service documentation in the EHR?
Your feedback is greatly appreciated
ABT
I would like to ask for interpretation of the guidelines for MCS. We are having an ongoing debate as to what has to be included in the documentation before MCS is coded and billed. My understanding is that all three components preservice work, intraservice work, and postservice work has to be in the chart as proof all elements are met. I do know the pre and postservice are not reported separately, and not included in the intraservice time; only intraservice time counts from administration of the first sedative and ending when the procedure ends, the patient is ready for recovery, and face-to-face time ends.
The guidelines under preservice work indicate: The preservice activities required for moderate sedation are included in the work described by each of these codes 99151-99157. Is this an all components for pre, intra, and postservice should be accessible to the coder, if not sedation is not coded? The debate is if it really is the responsibility of the coder to ensure the work has been done, or are they allowed to code the intraservice work, without the pre-and post service documentation in the EHR?
Your feedback is greatly appreciated
ABT