If medically necessary and properly documented, moderate sedation is a separately reported service.
Codes for moderate sedation are chosen and assigned based on three primary factors: 1.
Sedative strains are useful for individuals who need a relaxing sleep after a long day at work.
These can also be used for people who are very anxious.
initial 15 minutes of intraservice time, patient age 5 years or older 99157 Moderate sedation services provided by a physician or other qualified healthcare professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes intraservice time (List separately in addition to code for primary service)Description of Procedure (99152) The physician or other qualified health care professional performs presedation patient assessment; supervises or personally provides the administration of the sedating agent, with or without an analgesic; and supervises an independent, trained observer who monitors the patient’s level of consciousness and physiologic status throughout the procedure.
The patient is assessed continuously throughout the procedure to achieve an effective and safe level of moderate sedation.
The sedating agent(s), with or without an analgesic agent, is administered, and the patient is assessed continuously until an effective and safe level of moderate sedation and/or analgesia is achieved.
The patient is closely monitored by the sedating physician and additional doses of sedating and/or analgesic agent(s) are delivered as needed.
When reporting G0500, you may report additional time beyond the initial 15 minutes of intraservice time using 99153.
John Verhovshek, MA, CPC, is a contributing editor at AAPC.
You should report G0500 instead of 99151-99152 when reporting moderate sedation to Medicare patients in addition to designated GI endoscopy services.
You can find a list of designated GI endoscopy codes, here.
If a different provider, other than the provider performing the primary procedure, administers the moderate sedation, an independent observer is not required. Whether the patient is younger than five years of age; or five years old, or older. Per (May 2017), “the time spent on postservice activities that are required for moderate sedation are not included when calculating time and selecting the appropriate moderate sedation codes.” The CPT® codebook includes a helpful chart to determine the proper number of units of moderate sedation to report, based on intraservice time.