<iframe src="//www.googletagmanager.com/ns.html?id=GTM-MZ27W2" height="0" width="0" style="display:none;visibility:hidden">
❮ Back to Intermedix Blog

2017 CPT Update: Lower Time Requirement for Reporting Moderate Sedation

by Michael Driskill on December 30, 2016 at 2:29 PM

blog-2017-CPT-changes.png

For the 2017 calendar year, the American Medical Association, via Current Procedural Terminology (CPT), made several changes related to the CPT codes, documentation and time requirements for reporting moderate sedation services. The 2017 Final Rule reflects these new moderate sedation codes by applying relative value units (RVU) values, further supporting the need to be aware of and ensure that documentation supports the reporting of moderate sedation when appropriate.

CPT

Description

Total RVUs

99151

Moderate Sedation, same physician performing the procedure, initial 15 minutes, < 5 years

0.67

99152

Moderate Sedation, same physician performing the procedure, initial 15 minutes, 5 years or older

0.35

99153

Moderate Sedation, same physician performing the procedure, each additional 15 minutes

0.31

99155

Moderate Sedation, other physician performing the procedure, initial 15 minutes, < 5 years

2.63

99156

Moderate Sedation, other physician performing the procedure, initial 15 minutes, 5 years or older

2.15

99157

Moderate Sedation, other physician performing the procedure, each additional 15 minutes

1.63

 

As seen in the following chart, the new moderate sedation codes lower the threshold for the required Intraservice Time from 16 minutes to a minimum of 10 minutes. For instances in which sedation goes beyond 15 minutes, the additional increments of time (15 minutes) can be reported once the midway point is passed. For example, 23 minutes of Intraservice Time (8 minutes beyond the initial 15 minutes) is assigned the initial and additional code based on other coding parameters noted below:

 

Total Intraservice Time for Moderate Sedation

Patient Age

Moderate Sedation performed by the same provider performing the procedure that Moderate Sedation is supporting – Code(s)

Moderate Sedation performed by different provider performing the procedure that Moderate Sedation is supporting – Code(s)

Less than 10 Minutes

Any Age

Not Reported Separately

Not Reported Separately

10 – 22 Minutes

< 5 Years

99151

99155

10 – 22 Minutes

5 Years or Older

99152

99156

23 – 37 Minutes

< 5 Years

99151 + 99153 X 1

99155 + 99157 X 1

23 – 37 Minutes

5 Years or Older

99152 + 99153 X 1

99156 + 99157 X 1

38 – 52 Minutes

< 5 Years

99151 + 99153 X 2

99155 + 99157 X 2

38 – 52 Minutes

5 Years or Older

99152 + 99153 X 2

99156 + 99157 X 2

 

2017 Moderate Sedation CPT Codes and Descriptions

Beyond the actual new CPT code itself, the underlined areas reflect the key code description changes for 2017.

  • 99151 – Moderate sedation services provided by the same physician, or another qualified healthcare professional performing the diagnostic or therapeutic service that the sedation supports, that require 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
  • 99152patient age 5 years or older
    • 99153each additional 15 minutes (List in addition to code for primary service)
  • 99155 – Moderate sedation services provided a physician, another qualified healthcare professional other than the physician or another qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient younger than 5 years of age
  • 99156patient age 5 years or older
    • 99157each additional 15 minutes (List in addition to code for primary service)

Documentation Requirements

As a result of the new moderate sedation codes, it is important that key items are properly documented to ensure proper coding. These include:

  • Patient’s age, of which can be obtained from anywhere in the chart.
  • History, physical and diagnostic test(s) reviews, as appropriate when performing sedation.
  • Duration of moderate sedation. Intraservice time should be documented based on the specific number of minutes, as opposed to a range of time, to meet all payer requirements. If the physician does not document his/her intraservice time or if the time is less than 10 minutes, the service is not reportable.
  • Who provided the sedation and procedure(s).
  • Pre- and post-sedation assessment and/or monitoring.

Additionally, when the clinician is performing both the sedation and procedure, the medical record should reflect the identify of the trained observer who was present, when appropriate.

It is also important that providers do not rely on the drug name to communicate whether moderate sedation was provided. Providers need to use the terms “moderate” or “conscious sedation,” in combination with “intraservice time,” to ensure the reader of the record understands moderate sedation was performed and the time recorded was intraservice. It is important to note here that deep sedation is not reportable for these codes. 

Reporting Moderate Sedation and a Procedure when Performed by Different Clinicians

The existence and description of CPT codes 99155 – 99157 indicate there are instances when it is appropriate to have two clinicians involved in one encounter, where the performance of the procedure and sedation requires a second provider’s involvement. While there are a number of clinical reasons for services to be performed by different providers in certain instances, even if within the same group/specialty, it is important that the record not only document the clinical reason the second provider was required, but also the different requirements for the sedation when a clinician involved did not perform the initial evaluation and management service.

The documentation requirements regarding moderate sedation are the same regardless of whether the procedure and sedation were performed by one or multiple clinicians. When a second provider is called in to perform sedation, the documentation needs to address the pre-service and post-service work in addition to the intraservice time. Documentation of the patient’s history, physical and pre/post-sedation monitoring must be included by the provider performing the sedation.

As a result of the decreased threshold for the minimum time requirement and the RVU values the Centers for Medicare & Medicaid Services (CMS) assigned to the moderate sedation services, an increase in the volume reported is anticipated. Subsequently, with payments come heightened scrutiny regarding documentation, particularly when a second clinician is providing the sedation service. Given the substantial RVU variance when different providers are performing the sedation and related procedure, documentation must meet all requirements while simultaneously reflecting the medical necessity of having two clinicians involved.

CPT’s Delineation of Pre-service, Intra-service and Post-service Work

Beyond the CPT changes discussed thus far, CPT also provided additional details regarding what the new CPT codes include in the service (and RVU) and what counts toward intraservice time. Time spent performing items listed below as pre- and post-service work are included in the CPT code, but they should be excluded from intraservice time.

Pre-service Work

  • 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 experiences with anesthesia and/or sedation
  • Review of the patient’s family history in relation to sedation complications
  • Gathering of the patient’s present medication list
  • Gathering of the patient’s drug allergy and intolerance history
  • Focused physical examination of the patient with emphasis on:
    • Mouth, jaw, oropharynx, neck and airway for Mallampati score assessments
    • Chest and lungs
    • Heart and circulation
  • Gathering of vital signs, including heart rate, respiratory rate, blood pressure and oxygenation with end tidal CO2 when indicated
  • Review of any pre-sedation diagnostic tests
  • Completion of a pre-sedation assessment form (with an American Society of Anesthesiologist [ASA] Physical Status classification)
  • Retrieval of patient informed consent
  • Immediate pre-sedation assessment prior to first sedation doses
  • Initiation of IV access and fluids to maintain patency

Intra-service Work – How to Determine Time

Intraservice work time begins with the administration of the sedating agents and ends when the procedure is completed, the patient is stable for recovery status and the physician or other qualified healthcare professional providing the sedation ends personal, continuous face-to-face time with the patient.

Intraservice work includes ordering and/or administering the initial and subsequent doses of sedation agents. It requires continuous face-to-face attendance of the physician or another qualified healthcare professional and monitoring of the patient’s response to the sedating agents. Such monitoring may include periodic assessments of the patient, further administration of agents as needed to maintain sedation and monitoring of oxygen saturation, heart rate and blood pressure.

*If the physician or other qualified healthcare professional who provides the sedation services also performs the procedure supported by the sedation, the physicians or other qualified health care professional will supervise/direct an independent trained observer who will assist in monitoring the patient’s level of consciousness and physiological status throughout the procedure.

As you can see, CPT indicates “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.”  In other words, the clock starts when the drug is administered and ends when the physician leaves the patient’s room. 

Post-service Work

  • 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 following the procedure
  • Preparation of documentation regarding sedation service
  • Communication with family/caregivers regarding sedation service.

In light of the moderate sedation code revisions for 2017, there is an expected increase in the number of moderate sedation services reported in the Emergency Department (ED) setting. Reimbursement for this service has previously been limited by many payers. However, with the Medicare RVU assignment for these codes, Medicare and other payers who pay based on RVU values will begin reimbursing ED providers for moderate sedation services when documentation and billing requirements are met.

New Call-to-action
author avatar

This post was written by Michael Driskill

Michael Driskill is a director of coding operations at Intermedix.

Connect with Michael