HealthCare News

Moderate (Conscious) Sedation Coding Update

Issue: #396 SEP2017

Topic: Coding/Billing


Effective Date: July 1, 2017

Moderate (conscious) sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

Moderate sedation does not include minimal sedation, deep sedation or monitored anesthesia care.

Policy/Criteria

Benefits are not available for moderate (conscious) sedation administered by the operating surgeon or an independent trained observer supervised by the operating surgeon because it is considered included in the basic service and no additional reimbursement will be allowed.

Benefits will be allowed for moderate (conscious) sedation provided by a physician other than the health care professional performing the diagnostic or therapeutic service in children 12 years of age or younger when sedation is medically appropriate and necessary.

Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information.

Blue Cross Blue Shield of North Dakota (BCBSND) will follow the guidelines outlined in the CPT® manual for Moderate (Conscious) Sedation for Preservice Work, Intraservice Work and Postservice Work.

Coding/Billing Information for Eligible Services

CPT®99155

Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other 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
99156Initial 15 minutes of intraservice time, patient 5 years of age or older
99157Each additional 15 minutes intraservice time (list separately in addition to code for primary service)

Do not report 99151-99153 or 99155-99157 in conjunction with 94760-94762.

To bill add-on codes (99157 and 99153), a minimum of eight additional minutes of moderate sedation must be provided.

Non-Covered Services

CPT®99151Moderate 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
99152Initial 15 minutes of intraservice time, patient 5 years of age or older
99153Each additional 15 minutes intraservice time (list separately in addition to code for primary service)

Gastrointestinal Endoscopic Services

BCBSND made the following change to billing and coding of anesthesia services when billed by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that sedation supports. This change was made because of the rules implemented by the Center for Medicare and Medicaid Services (CMS) on Jan. 1, 2017. Effective July 1, 2017, the following guidelines apply for eligible services:

HCPC Level II®G0500Moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that 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 of age or older
CPT®99153Each additional 15 minutes intraservice time (list separately in addition to code G0500 for primary service)

Qualifying gastrointestinal endoscopic services include those CPT®/HCPCS codes identified and published by CMS as eligible to be billed with G0500 (CMS-1654-F Moderate Sedation Work Values Table).

Sources

  1. CMS-1654-F Moderate Sedation Work Values Table
  2. CPT® 2017
  3. HCPC Level II® 2017