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Outpatient Facility Coding Alert

Reader Question:

Know CPT® Guidelines on Reporting Moderate Sedation Administration

Question: I have two patients (over 5 years of age) receiving moderate sedation. One receives just 4 total minutes and the other receives 25 total minutes. Both are administered by the same provider as the procedure. How do I code each case, respectively?

New Jersey Subscriber

Answer: With respect to the first case, you may not submit a moderate sedation code in addition to the procedure code. CPT® states that the physician must report at least 10 minutes of intra-service time in order to report the initial moderate sedation code. Any time administering moderate sedation below the 10-minute mark is considered an inclusive component of the underlying procedure.

As for the second case, remember that you should rely on the CPT® moderate sedation timetable in order to know which set of codes to apply. For moderate sedation lasting between 10 and 22 minutes on a patient over 5 years of age, you should apply code 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). Since the patient receives a total of 25 minutes of moderate sedation, CPT® instructs you to also apply code +99153 (… each additional 15 minutes intraservice time [List separately in addition to code for primary service]) for any duration between 23-37 minutes.  

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