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conscious sedation documentation requirements

Sarah Posted Thu 17th of November, 2016 13:10:59 PM
what kind of documentation is needed in the procedure report in order to bill for these new codes?
SuperCoder Answered Fri 18th of November, 2016 04:39:21 AM


Moderate sedation codes are (patient) age and time specific. Codes 99143-99145 identify sedation provided by a physician who also performs the primary procedure. When the primary physician provides moderate sedation (as described by 99143-99145), an independent, trained observer must be on hand to help monitor the patient.

Documentation should provide proof of the observer’s presence and note that the observer monitored the patient’s cardiorespiratory functions during the moderate sedation.

Report 99143-99150 by “intra-service” time. Intra service time starts with the administration of the sedation agent(s) and ends at the conclusion of personal contact by the physician providing the sedation.

Codes 99148-99150 identify sedation provided by a physician who does not perform the primary procedure.

Documentation should include the name of the procedure, medication names, dosages and routes of administration, who administered the medication(s) (physician or observer), notations of ongoing assessments and vital signs monitoring during MCS.

Kindly let us know, if you need any further assistance.

Thank you.

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