Coding Corner: CPT Changes for Conscious Sedation

Download PDF

Conscious sedation will no longer be bundled into procedures effective 1/1/17.  There are 6 new CPT codes:

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.

99152 - 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 age  5 years or older.

99153 - 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.

99155 – Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other 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.

99156 - Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient age 5 years or older.

99157 - Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes intraservice time.

The CPT manual states that only intraservice time can be reported.  The manual also specifies what is considered “Preservice Work”, “Intraservice Work” and “Postservice Work”. The following is a breakdown of each area:

Preservice Work – this is not included when determining intraservice time for reporting:

• 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
• Family history of sedation complications
• Summary of the patient’s present medication list
• Drug allergy and intolerance history
• Focused physical examination of the patient with emphasis of:
  • Mouth, jaw, oropharynx, neck and airway for Mallampati score assessment
  • Chest and lungs
  • Heart and circulation
• Vital signs, including heart rate, respiratory rate, blood pressure and oxygenation with end tidal CO2 when indicated
• Review of any pre-sedation of diagnostic tests
• Completion of a pre-sedation assessment form (with an American Society of Anesthesiologists (ASA) Physical Status Classification)
• Patient informed consent
• Immediate pre-sedation assessment prior to first sedating doses
• Initiation of IV access and fluids to maintain patency

Intraservice Work – Intraservice time is used to determine the appropriate CPT code to report moderate sedation services

• Begins with the administration of the sedating agent(s)
• Ends when the procedure is completed, the patient is stable for recovery status, and the physician or other qualified health care professional providing the sedation ends personal continuous face-to-face time with the patient
• Includes ordering and/or administering the initial and subsequent doses of sedating agents
• Requires continuous face-to-face attendance of the physician or other qualified health care professional
• Requires monitoring patient response to the sedating agents, including:
  • Periodic assessment of the patient
  • Further administration of agent(s) as needed to maintain sedation
  • Monitoring of oxygen saturation, heart rate, and blood pressure

Postservice Work – once continuous face-to-face time with the patient has ended, additional face-to-face time with the patient is not added to the intraservice time, however, it is considered as part of the post service work.  The following postservice work components are not included when determining intraservice time:

• 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 time.

There are additional RVUs to the radiologists when moderate sedation is documented appropriately.