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Conscious Sedation

Kerry Posted Thu 16th of February, 2017 10:48:40 AM
Is it the provider that bills the conscious sedation? When a patient is sent to the cath lab and the RN (independent trained observer) starts the sedation before the provider enters the lab but states conscious sedation initiated then documents when the physician enters the cath lab which time would you use? Because the provider is responsible for the RN who is administering the sedation can you count her time when the provider is not in the lab.
SuperCoder Answered Sat 18th of February, 2017 11:49:01 AM

Hi Kerry,

In this scenario, we will be using the time when RN (independent trained observer) starts the sedation before provider enters the lab.  Reason being:

  • Sedation time begins with the administration of the sedating agent(s) (i.e., with the start of the first IV push of the sedating drug).

  •   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;

AMA CPT Assistant 2006 and 2011, which describes an independent trained observer administering the agent under the order by the physician and the physician could report the service if it is properly documented as formal moderate sedation record. Hope it helps.


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