Don't have a TCI SuperCoder account yet? Become a Member >>

Regular Price: $24.95

Ask An Expert Starting at $24.95

Have a medical coding or compliance question? Don’t sacrifice your valuable time to endless research. Choose Ask an Expert to get clear answers from the TCI SuperCoder team. And here’s a tip for the budget-conscious: Select the 12-question pack to get the best rate per question!

Browse Past Questions By Specialty

+View all

Documentation guidelines for moderate sedation

Deaconess Posted Wed 04th of January, 2017 15:23:42 PM
Hello Hoping someone can help with my questions re documentation for billing moderate sedation. 1. What information exactly should the physician's procedure report include specific to moderate sedation? 2. Is it acceptable for the physician to refer to the procedure log for the stop and start time? 3. Is it acceptable for the physician to refer to the nurse's log and/or the medication administration log for the name of the nurse administering the sedation, the medications given, including route and dosage? 4. Regarding the documentation of the ongoing assessment of the patient during the procedure: this information is entered into a log every 5 minutes, or more frequently if needed. Does this information also have to be included in the physician's report? Thank you very much. Molly O'Connor Billings Clinic
SuperCoder Answered Thu 05th of January, 2017 03:03:02 AM

Hi,

1. What information exactly should the physician's procedure report include specific to moderate sedation?

Documentation should provide :

a) proof of the observer’s presence and note that the observer monitored the patient’s cardiorespiratory functions during the moderate sedation.

            Also, 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.

2. Is it acceptable for the physician to refer to the procedure log for the stop and start time?

Yes, the physician can ask the nurse to note the start and stop time.

3. Is it acceptable for the physician to refer to the nurse's log and/or the medication administration log for the name of the nurse administering the sedation, the medications given, including route and dosage?

Yes, procedural sedation and analgesia in the ED must be supervised by an emergency physician or other appropriately trained and credentialed specialist.

4. Regarding the documentation of the ongoing assessment of the patient during the procedure: this information is entered into a log every 5 minutes, or more frequently if needed. Does this information also have to be included in the physician's report? -

Yes.

Hope this helps!

 

Related Topics