Moderate Sedation Becomes Separately Payable in 2017

ADVOCATE recently reported on the CPT changes affecting radiology in 2017.  One of the biggest changes is in interventional radiology and the new ability to separately bill and be paid for moderate sedation provided during certain procedures.  While trend has been to bundle payments, this is an opportunity to unbundle and receive additional payment for services that were previously bundled in the base procedure code.

According to the AMA/CPT, “Moderate/Conscious sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation.  No interventions are required to maintain cardiovascular function or a patent airway, and spontaneous ventilation is adequate.”

Previously, the compensation for moderate sedation was bundled into the payment for the procedure code(s) that were identified by CPT with a bullseye symbol.  In 2017, the bullseye and the existing moderate sedation codes were deleted and replaced with a new set of codes that may be billed separately from the procedure.

The criteria for use and the new codes are listed below:

  • Time criteria:  Codes for initial (first 15 minutes) and add-on codes for each additional 15 minutes.
  • Age criteria:  Codes for age 5 and above or less than 5 years old.
  • Provider criteria:  Codes are identified by sedation provided by the physician or other qualified health care provider performing the procedure or sedation for a procedure performed by a different physician or other health care provider:

99151 – Moderate sedation, same physician, first 15 minutes, less than 5 years old

99152 – Moderate sedation, same physician, first 15 minutes, age 5 or older

99153 – Moderate sedation, same physician each additional 15 minutes

99155 – Moderate sedation, different physician, first 15 minutes, less than 5 years old

99156 – Moderate sedation, different physician, first 15 minutes, age 5 or older

99157 – Moderate sedation, different physician each additional 15 minutes

The time, referred to as intraservice time, is based on face-to-face time by the physician. Intraservice time begins with the initiation of the sedating agent.  It requires continuous face to face attention of the provider, and monitoring by an independent trained observer of the patient’s response to the sedation, periodic reassessments, and vital signs including oxygenation, heart rate, and blood pressure.

The intraservice time ends when the procedure is completed, the patient is stable, and the provider providing sedation feels comfortable leaving the face to face care of the patient.

It is important to note that routine pre-and post- service care should NOT be counted as intraservice time.

In 2017, the threshold for initial intraservice time is 15 minutes.  Historically, for time-based codes, a billable unit of time is attained when the midpoint has passed. However, in the case of moderate sedation, there is a CPT instruction that any sedation less than 10 minutes should not be reported.

The importance of proper documentation of moderate sedation can’t be stressed enough.  Proper code selection and accurate reimbursement depend on clear and concise documentation. The language below can be adopted and used in reporting these new codes.

Sample Report Verbiage:

Under physician supervision, Versed and fentanyl administered intravenously for moderate

sedation. Pulse oximetry, heart rate, and BP are continuously monitored by an independent trained observer present. The physician spent __#__ minutes of face to face sedation time with the patient.

As always, ADVOCATE will keep you up to date on this and all issues impacting radiology as they become available.

Jennifer Bash, RHIA, CPC, CIRCC, RCC
Coding & Documentation Education Manager