One of the more substantial changes in CPT in 2017 involves the guidelines and reporting of administration of moderate sedation. CPT defines moderate sedation as the administration of medications to depress a patient’s consciousness during a procedure. Moderate sedation is also sometimes referred to as conscious sedation (these terms are synonymous so whether the medical records you are coding use the term moderate sedation or conscious sedation the guidelines outlined in this article will apply).
When a patient is under moderate sedation, they are still able to respond to commands (sometimes that response is based on a request from the physician that they act on a specific command and other times those responses are involuntary based on a reaction to stimulation). Moderate sedation is different from other forms of anesthesia, such as monitored anesthesia care (MAC) and general anesthesia because interventions are not required to help the patient maintain cardiovascular or respiratory functions (the patient is able to breathe on their own without being intubated and connected to a ventilator). When we are coding for the “administration” of moderate sedation, we are capturing the physician’s work of overseeing the patient while they are given sedating medications (typically by a staff member such as a nurse) and continuing to monitor the patient’s heart rate, blood pressure, and oxygen levels and ordering or providing further sedating medications as needed throughout the procedure.
Prior to 2017, the CPT manual contained Appendix G which was a comprehensive list of procedures throughout the CPT manual that included the administration of moderate sedation when moderate sedation was provided by the physician performing the procedure for which the patient required the sedation. These codes were represented throughout the CPT manual by an icon to their left that looked like a little bull’s eye which was a signal to coders not to report administration of moderate sedation separately because the work of administering moderate sedation and the fee for performing that service was already built into the surgical code itself. However, based on a recent review, the AMA determined that many of the surgical procedures assigned this status of including the administration of moderate sedation were no longer being performed under moderate sedation. Because physicians were being paid to administer moderate sedation since the fee for doing so was built into the surgical code itself, many CPT codes which included the administration of moderate sedation were potentially overvalued.
On the other hand, for surgical procedures that did not routinely include administration of moderate sedation, the CPT manual offered codes to report moderate sedation services separately, but those codes were written to report sedation times with a minimum total time of 30 minutes or more. Based on advances in modern medicine, procedures now take less time than they did when these old codes were written. In order to report a time based code in any portion of the CPT manual, including for administration of moderate sedation, the physician must meet or exceed the “half time” of that code; therefore, for administration of moderate sedation which was written for a minimum of 30 minutes, unless the moderate sedation service was longer than 15 minutes (exceeding half of the time specified by the code), the physician was ineligible to report administration of moderate sedation at all. This resulted in a concern that certain surgical procedures were being undervalued since physicians were doing additional work in administering moderate sedation that they had no way to be paid for.
Based on both of these concerns, the AMA decided to delete the entire Appendix G for 2017 and revise the approximately 400 codes contained within that appendix so that no codes within the CPT manual included by definition the administration of moderate sedation. Any time moderate sedation is administered now, it will be necessary to report the moderate sedation with an additional CPT code(s). AMA also decided to delete the existing CPT codes for administration of moderate sedation and publish six new codes that were differentiated based on patient age and reported administration of moderate sedation in increments of 15 minutes to more accurately represent these services in modern medicine.
The six new codes for administration of moderate sedation in 2017 are as follows:
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 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 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 consciousness and physiological status; each additonal 15 minutes of intraservice time (list separately in addition to the primary service)
99155: Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified healthcare 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 healthcare 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 healthcare professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes of intraservice time (list separately in addition to code for primary service).
As you can see, the first three codes – CPT 99151, 99152, and 99153 – are to be reported by the physician or other qualified healthcare professional (e.g., a physician’s assistant, nurse practitioner, or other professional licensed to perform the procedure) who is also performing the diagnostic or therapeutic procedure that the patient needs to be sedated for.
- CPT 99151 should only be reported on claims for a patient who is under 5 years old.
- CPT 99152 should only be reported on claims for a patient who is 5 years old or over 5 years old.
- Both codes 99151 and 99152 report the first 15 minutes of intraservice time which we will define in just a moment.
- CPT 99153 can be reported for patients of any age and reports each additional 15 minutes of intraservice time. CPT 99153 is an add on code which means that it can only be reported when another code known as a primary CPT code is on the claim (add on codes can never be reported by themselves). In this case, add on code 99153 is designed only to be reported with 99151 or 99152.
- As we discussed earlier in this article, in order to report a code for moderate sedation which is based on time, the documentation must specify the total intraservice time. When reporting CPT 99151, 99152, 99155, or 99156, at least 10 minutes must be spent administering moderate sedation in order to report these initial codes because the CPT manual specifically states not to report any code for less than 10 minutes spent administering moderate sedation. For add on codes 99153 and 99157, there must be at least 8 additional minutes of time spent administering moderate sedation beyond those initial 15 minutes in order to report the add on code. There is an excellent table in the CPT manual that assists coders in reporting the appropriate codes and number of units based on the total time spent administering moderate sedation.
To fully understand these codes and how to apply them, we also need to understand a couple of the terms used within the code description.
- The first term we see is “requiring the presence of an independent trained observer.” The CPT guidelines define an independent trained observer as an individual who is qualified to monitor the patient during the procedure and who has no other responsibilities during the procedure. For example, let’s say a physician is performing a diagnostic colonoscopy (CPT 45378). This same physician is also administering moderate sedation during the colonoscopy. The physician asked a physician’s assistant (PA) that he works with to be the independent observer and monitor the patient during the procedure. The PA must be solely dedicated to monitoring the patient (he cannot assist with the procedure, leave to provide an update to the patient’s spouse, or perform any other duties related to the procedure, other than monitoring that patient). His sole focus should be on monitoring that patient.
- The second term we see is “intraservice time.” This term defines what time should be counted in order to report the appropriate CPT code(s). CPT defines intraservice time as beginning when the sedating medication is administered and ending when the procedure is finished, the patient is stable and in recovery, and the continuous face to face time by the physician or qualified health care professional ends. The time that exists between administering the sedating medication and ending that face to face monitoring of the patient is the only time that should be counted in order to report these codes. The physician will have pre-service duties which may include asking the patient important questions about their history like mediation allergies and any past reactions they have had to anesthesia as well as post-service duties such as updating the patient’s caregiver, writing notes summarizing the sedation service, and writing discharge paperwork for the patient. While these pre and post services are important, the time the physician spends on these services should not be counted for purposes of reporting administration of moderate sedation.
The remaining CPT codes – 99155-99157 – are written exactly the same as the codes we just discussed with one notable exception. They are intended to be reported by a physician or other qualified healthcare provider other than the physician or qualified healthcare provider performing the procedure the patient requires sedation for. Because this other provider is by definition not involved in other duties related to the procedure, he does not need an independent trained observer present (he can personally monitor the patient throughout the procedure while they are under moderate sedation).
Example: A 35 year old patient is having a diagnostic bronchoscopy for an abnormal chest x-ray that appeared to show a mass in the right bronchus. The physician performing the procedure administers Midazolam (the drug used for sedation). His PA is in the room and monitors the patient throughout the entire procedure. The bronchoscope is passed transorally (through the mouth) down the trachea and into the right bronchus. Through the scope the physician examines the right mainstem bronchus and its branches carefully in the region of the noted abnormality on chest x-ray, but no mass is found. He then moves the scope over to the left mainstem bronchus and carefully examines the main bronchus and its branches for any abnormalities. Finding no masses in either bronchus, the scope is withdrawn. The patient tolerates the procedure well and is transported to recovery in stable condition. The total monitoring time is 23 minutes.
In this example, we can report CPT 31622 for the diagnostic bronchoscopy which includes the work of passing the scope and diagnostically examining the airway. We can also report the administration of moderate sedation for the physician since he has met the CPT guidelines for reporting moderate sedation (he has documented the total intraservice time as 23 minutes, and he notes that he had an independent trained observer present to monitor the patient throughout the procedure). Because we know the total intraservice time is 23 minutes, and the patient is 35 years old, we will report CPT 99152 for the first 15 minutes of intraservice time (again this code is based on the patient’s age and the fact that the same physician performing the bronchoscopy is also administering the moderate sedation). We will also report add on code 99153 x1 for the additional 8 minutes of moderate sedation (8 minutes exceeds half of the 15 minutes defined by CPT code 99153 and, the physician, therefore, can report this additional time separately).
