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Moderate Sedation for colonoscopies

Cheryl Posted Thu 31st of October, 2019 09:32:40 AM
This is in regards on how to count the time for the intraservice work. In this example the sedation was started at 9:30am, the colonscopy was finished at 10:24 am, the recovery start time was 10:33 and patient was monitored (vital signs, etc) until 11:03 am when the patient was discharged. Do you only start counting the total intraservice work, as in this case, from 9:30 until 10:24, or do you also count the time spent in recovery (10:33-11:03) as part of the intraservice time?
SuperCoder Answered Fri 01st of November, 2019 05:32:36 AM

Hi,

 

Thanks for the question.

 

Intraservice time starts with administration of the sedation agents, requires continuous face-to-face attendance, and ends at the conclusion of personal contact by the physician providing sedation.

Moderate sedation intraservice time includes the requisite, continuous face-to-face attention of the provider and monitoring of the patient’s response to the sedation, periodic reassessments, and vital signs including oxygenation, heart rate, and blood pressure.

Intraservice time is standard across all moderate sedation services, regardless of specialty.

The moderate sedation intraservice time ends when the procedure is completed, the patient is stable, and the provider providing sedation ends personal face-to-face care of the patient.

 

What does not qualify as intraservice work

The new CPT® guidelines include a list of pre- and post-work components that are not included in intraservice time.

Pre-service work components not included:

  • A thorough screening history involving assessment of the patient’s past medical and surgical history with particular emphasis on cardiovascular, pulmonary, airway, or neurological conditions, review of the patient’s previous experience with anesthesia or sedation and any family history of sedation complications, summary of the patient’s present medication list and any drug allergy and intolerance history.
  • A physical exam including focused emphasis on the mouth, jaw, oropharynx and airway for Mallampati score assessment, chest, lungs, heart and circulation, vital signs includi-ng oxygenation with end tidal C02 when indicated.
  • A review of any pre-sedation diagnostic tests, completion of a sedation assessment form and obtaining informed consent.
  • Starting IV access and fluids to maintain patency.

 

The following post-service work components are not included:

  • Assessment of the patient’s vital signs, level of consciousness, neurological, cardiovascular and pulmonary stability in the post-sedation recovery period.
  • Assessment of the patient’s readiness for discharge.
  • Documenting the sedation service.
  • Communicating to family members or caregivers regarding the sedation service.

 

Please also check below link for better understanding:

https://www.supercoder.com/coding-newsletters/my-pulmonology-coding-alert/heed-these-in-house-moderate-sedation-changes-153962-article

 

Thanks

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