99143
Moderate sedation services, provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; younger than 5 years of age, first 30 min intra-service time
99144
Moderate sedation services, provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; age 5 years or older, first 30 min intra-service time
99145
Each additional 15 min intra-service time
99148
Moderate sedation services, provided by a physician other than the health care professional performing the diagnostic or therapeutic service that the sedation supports; younger than 5 years of age, first 30 min intra-service time
99149
Moderate sedation services, provided by a physician other than the health care professional performing the diagnostic or therapeutic service that the sedation supports; age 5 years or older, first 30 min intra-service time
99150
Each additional 15 min intra-service time
Currently the Medicare system and many commercial carriers allow additional payment for moderate sedation as long as it is not for a code that includes sedation services in the descriptor (see CPT-4 Book, current year, Appendix G). At the time of this writing, the moderate sedation codes have been assigned a status indicator of “C” under the Medicare Physician Fee Schedule, designating that these services are carrier priced—meaning that each individual Medicare intermediary determines the amount of payment appropriate for the service. At this time, CMS has not established relative value units for these services and payments vary based on the carrier and the region of the country. For commercial payors, rates range from $40 to 200 per unit, depending on the geographical area of the country and the specific carrier.
The confusion in billing for sedation services occurs when a separate physician delivers only a part of the sedation services, such as the triage, evaluation, and sedation plan followed by his supervision of a sedation nurse. There is no coding reference for this type of activity. However, it is important for the physician to support the need for sedation service. For example, it is understood that in young children, sedation services are necessary to perform procedures. Careful documentation is critical in the event that at a later period (maybe even years later), the reviewer disagrees with the necessity of having a separate physician provide the sedation service. Carriers may take up to 7 years to contest or disagree with a charge, but providers also should understand that if government agents believe fraud was involved, they may go back indefinitely. Therefore, a well-documented record that explains your thought process of why sedation is needed is the best protection you can have in defending health care scrutiny.
Key Components of Evaluation and Management Services Documentation
All evaluation and management services have specific components. There are seven components that assist coders in translating the documented work into the appropriate code selected, of which only three are required (key) components that must be documented for all visits. These three key components are: (1) patient history, (2) physical examination, and (3) medical decision-making.
The first specific key component is the patient history. The history section contains several elements, including:
The chief complaint/presenting problem
The history of present illness
A review of systems
The past medical, family, and social history of the patient
This history section should include the justification and rationale for requiring a separate physician to provide the sedation services.
The second of the key components is the physical examination. The examination documentation must contain up-to-date information regarding the patient’s condition at the time of the exam and should describe the results and findings of body areas or organ systems that are actually examined by the physician during the encounter. It is specifically noted that this type of physical examination should be based on the physician’s clinical judgment and directed toward that which is medically indicated to support the medical decision.
The final of the three key components is the medical decision. The medical decision is commonly referred to as “the thought process of the physician.” It should be a statement (or statements) that represent the complexity of the decision-making process involved in selecting a plan for the management and delivery of sedation services. This assessment should include the critical elements that were considered in deriving the sedation plan as well as the intended depth of sedation required. There is not a clearly defined level of risk involved in providing sedation. The CMS guidelines best define the degree of risk involved in making these medical decisions within the low to moderate decision-making category, depending on the nature of the presenting problem(s) of the patient and the procedure.
If the evaluation and management plan of the sedation is performed by a provider separate from that who will be delivering and monitoring the sedation, it would be appropriate to charge for the initial services under evaluation and management codes. These concurrent care services are payable when the physician plays an active role in the patient’s treatment or the treatment plan. The medical diagnosis should reflect the need for medical evaluation and management as a necessity for the delivery of subsequent sedation services.
Deep Sedation (MAC)
Deep sedation is defined as a drug-induced depression of consciousness during which patients cannot be easily aroused following repeated or painful stimulation. The ability to independently maintain ventilatory function during this time may be impaired and assistance may be required to maintain the airway.
One cannot discuss deep sedation and MAC without understanding the differences. MAC is light, moderate, or deep sedation where the provider of MAC must be prepared and qualified to convert to general anesthesia. Many MAC services do not require the delivery of any agents; although it is unlikely, the patient’s risk level requires them to be prepared to convert to a general anesthetic.
Insurance companies are interested in addressing the rules surrounding medical necessity for the separate anesthesia provider as this adds to the cost of the service. The American Society of Anesthesiologists’ (ASA) position statement defines medically necessary services as those that alleviate emotional or psychological duress or pain while undergoing a surgical, obstetrical, or other therapeutic/diagnostic procedure. The ASA supports that the level of sedation should be based on the medical judgment of a physician who is trained in anesthesia, in conjunction with the physician performing the procedure. The targeted level of sedation must consider all aspects of the patient’s health as well as the procedure to be performed. Many insurance companies do not recognize this broad definition and relate the medical necessity to the ASA status of the patient, requiring additional diagnosis (ICD-9 codes) to accompany the reason for the procedure to support the need for separate anesthesia providers. The ASA status is the assignment of a P code to assess the degree of a patient’s “sickness” or “physical state” prior to selecting the anesthetic or prior to performing surgery. It helps determine the “risk” that a patient presents, describing patients’ preoperative physical condition. Some insurance companies designate an ASA status of P3 or higher to justify the need of a separate anesthesia provider.
In billing an anesthesia code from the CPT-4 book, physician providers are held to the same requirements of documentation as that which is required from an anesthesia provider. This includes:
1.
A preoperative assessment that would review abnormalities of the major organ systems
2.
An airway assessment
3.
A history of any previous experience with sedation or anesthetics
4.
A review of drug allergies and current medications
5.
A review of tobacco, alcohol, or substance abuse
6.
The time and nature of last oral intake
7.
Assignment of the ASA physical status
During the actual medical procedure, the appropriate monitoring must be performed and would include:
