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Moderate Sedation

Jana Posted Fri 17th of February, 2012 15:25:11 PM

Some of the Doctors have asked me when the time starts and ends for Moderate sedation. I explained to them that time starts when the medication is given and time stops when the Doctor breaks face to face after procedure is completed. Some of the Doctors feel they will not be able to meet the 16 min. minimal time. The question that has been asked is if the Doctor leaves the room after the procedure and comes back to check on the patient is that time counted?

Thank you,
Jana Knox

SuperCoder Answered Fri 17th of February, 2012 16:02:31 PM

No that time won't be counted.

According to the CPT Guidelines, "Intraservice time starts with the administration of the sedating agent(s), requires continuous face-to-face attendance, and ends at the conclusion of personal contact by the physician providing the sedation." The new CPT codes for moderate sedation and the corresponding Relative (Value) Update Committee recommended work values require that the physician be in attendance during the intraservice period of sedation. If a drug is administered to accomplish "moderate sedation," then the time claimed by the physician for the moderate sedation codes submitted must correspond to the documented personal attendance by the physician providing the sedation. Note that a physician cannot order that a drug be given and then leave the patient. For example, a radiologist cannot order a medication be given to induce moderate sedation for an MRI study and then leave the patient with a nurse in attendance to monitor the patient status. This does not meet the requirement of continuous face-to-face attendance by the physician.

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