Rule Change: If You’ve Never Reported Moderate Sedation Before, Read This

cpt 2017 moderate sedation reporting change

It’s time to start adjusting your brain to the new reality about moderate sedation coding. For years, you’ve trained yourself to not report your provider’s moderate sedation separately when CPT® marked the procedure code with a circle with a center dot symbol and listed the code in Appendix G.

But the 2017 Medicare Physician Fee Schedule and CPT® 2017 want to change all that. CPT® 2017 removes the symbol from more than 400 codes, and that means you need to report the moderate sedation code if you want to be paid for it.

Codes for vascular procedures, electrophysiology, and gastroenterology procedures dominate the list of codes that carried the moderate sedation symbol in 2016 and before, so if you code for those services, you need to pay particular attention to the changes coming for moderate sedation.

Focus on Age and Time to Find Right Codes

In addition to changing the rules for reporting moderate sedation, CPT® changes the codes, too. CPT® 2017 deletes current moderate sedation codes 99143-+99150. The replacement codes are similar to the old codes (with some variations in time requirements), but if you never used the old codes, that news doesn’t help you much.

You’ll choose from these 2017 codes when a physician or other health care professional provides the moderate sedation for a procedure she’s performing herself (bold added):

  • 99151, Moderate sedation services provided by the same physician or other qualified health care professional 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; initial 15 minutes of intraservice time, patient younger than 5 years of age
  • 99152, … initial 15 minutes of intraservice time, patient age 5 years or older
  • +99153, … each additional 15 minutes intraservice time (List separately in addition to code for primary service).

Key points: Code 99151 applies to the first 15 minutes of moderate sedation services for a patient younger than five. If the patient is five or older, use 99152 for the first 15 minutes. Code +99153 applies to each additional 15 minutes regardless of patient age.

Worth noting: Additional new codes 99155, 99156, and +99157 look a lot like 99151-+99153 but apply when someone other than the surgical provider performs the moderate sedation services.

Here’s Proof Reviewing the Proposed MPFS Is Helpful

The proposed 2017 Medicare Physician Fee Schedule provides insights into why the change is happening. The short version is that Medicare factored payment for moderate sedation into procedure codes with the moderate sedation symbol. Medicare has noticed anesthesia getting reported separately for scope procedures with the moderate sedation symbol and didn’t want to pay for both the anesthesia performed and the moderate sedation not performed.

After considering different options, like removing the symbol from only certain codes, the decision was to streamline and have providers report and get paid for moderate sedation only when they perform it.

What does this mean to you? If you report any services listed in AMA’s CPT® 2016 Appendix G, you’ve got some work to do. You need to review the new codes, read the guidelines, and ensure that your documentation clearly documents everything you need to support reporting the new codes. The plan is to reduce RVUs for those Appendix G codes because moderate sedation will no longer be included, so reporting moderate sedation when appropriate is crucial to your goal of bringing in every dollar you deserve.

Gastro coders beware: Keep an eye on HCPCS 2017. You can expect to use a new G code for Medicare claims instead of 99152 to better reflect the work involved:

Moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service (excluding biliary procedures) that 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; initial 15 minutes of intra-service time; patient age 5 years or older.

Watch private payer policies to see if they accept the new G code, too.

How About You?

Are you ready to start reporting moderate sedation? Are you concerned about the RVUs changes?

 

About 

Deborah concentrates on coding and compliance for radiology and cardiology, including the tricky world of interventional procedures, as well as oncology and hematology. Since joining The Coding Institute in 2004, she’s also covered the ins and outs of coding for orthopedics, audiology, skilled nursing facilities (SNFs), and more.

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16 Comments For This Post

  1. Carol Hodge, CPC, CCC Says:

    With the new guidelines for moderate sedation, who would be the actual person need to be administrating the medication during the procedure that moderate sedation could be billed for?

  2. Deborah Marsh Says:

    That’s a really important question. From what I’ve been finding, the answer is that you need to look at scope of practice rules in place for your state, professional associations, organization, and the like. Here are some resources that may help:
    http://aamsn.org/faq
    https://sedationcertification.com/resources/position-statements/position-statements-by-state/clickable-map/

  3. Susan Says:

    I’m not sure I understand this article. It does not say the sedation codes are going away, they say in Appendix B, they are deleting old codes, re-adding new codes with the the bulleyes that denotes which new codes are to be added with conscious sedation included in it’s service. That is most of them.

    they are deleting Appendix G and the bulls eye but reading them back per Appendix B with the bulleyes. Please see page 734 2017 CPT

  4. Deborah Marsh Says:

    Hi, Susan – I believe your question stems from an error in wording in the AMA CPT® code book’s intro to Appendix B. The 2017 errata document changes that wording to state that the bullseye moderate sedation symbol has been deleted for 2017. The corrected wording also states that in App. B the moderate sedation symbol with the strikethrough indicates deletion of the symbol. The errata and corrections document is available at https://www.ama-assn.org/practice-management/errata-technical-corrections

    I hope that helps, and thanks for bringing up an important issue!

  5. Tara Says:

    If the sedation is provided by an RN, which is within her scope, and is provided under direct supervision but in POS 22, the professional charges for the sedation still can’t be billed, correct? Wouldn’t it only be facility charges that can be sumbitted?

  6. Miriam Says:

    With the new guidelines for moderate sedation would it be correct to only bill the sedation codes and not the drugs used? Or both?

  7. Dee Says:

    Does anyone have the answer to Tara’s question above? If the sedation is performed by RN/cath lab tech under supervision and by order of the provider, in a facility, can the provider report the moderate sedation service?

  8. Debbie Says:

    Does anyone have the answer to Tara’s and Dee’s questions above? If the sedation is performed by RN/cath lab tech under supervision and by order of the provider, in a facility, can the provider report the moderate sedation service?

    What is POS22? So these codes are charged by the facility and by the provider?

  9. Theresa Says:

    If someone can answer Tara and Dee’s questions above, it would be greatly appreciated and helpful. We have a similar situation/question. Our hospital (OP facility) has ACLS certified RN’s administering the moderate sedation, while the surgeon performs the (GI) procedures and are charging for the procedure plus the MS CPT’s 99156 and 99157. Would this be correct?

  10. Julie Says:

    Yes 99152 is used when physician who does the procedure supervised the
    Nurse administering the sedation. If another physician PA or CRNP
    Administered the sedation use 99156. Only facility side can use 99153 for addl time after
    For addl time after first 15 minutes. POS 22 is place of service /22 is Outpatient

  11. Tara Says:

    POS 22 is for a hospital based clinic. This is reported on a 1500 professional claim. When a service is provided in a hospital based clinic, the provider’s charges are submitted on a 1500 and the facility charges are submitted on a UB.

    Anyone have an answer to my questions above?

  12. Deborah Marsh Says:

    Hi, all – For the question about coding for physician-provided moderate sedation when the service is in a facility, here are some details that may help.

    The MPFS gives higher values to 99151, 99152, and G0500 performed in the nonfacility setting vs. the facility setting. For instance, the national MPFS nonfacility price for 99152 is $52.04 and the facility price is $12.56. The difference is in the PE RVUs, suggesting Medicare took into account how the services will differ in those settings for the physician.

    All three codes also have a PC/TC indicator of 9, meaning the concept of professional/technical doesn’t apply.

    Another piece of the puzzle is that the MPFS RVU files have a Facility NA Indicator column. For all three codes, the column is blank, as opposed to stating NA. The presence of NA would mean “the procedure is rarely or never performed in the facility setting,” according to the explanatory PDF that accompanies the RVU files. (The RVU files are at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files-Items/RVU17A.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending.)

    Code +99153 is a little different. It does have an NA in the Facility NA Indicator column (remember that means rarely/never performed in a facility), and its PCTC indicator is 3, which means it’s a technical component only code (i.e., staff and equipment). There are no work RVUs for +99153 (99151, 99152, and G0500 do have work RVUs).

    I found a similar rationale here: https://www.libmaneducation.com/professional-billing-moderate-sedation-physician-performing-procedure-facility-site-service/

    Hope that’s helpful – Would love to hear if anyone has gotten specific instructions from a payer!

  13. Tara Says:

    My question is pertaining to when an RN performs the conscious sedation, not a physician. I think the codes that would by applicable would be from the 99155-99157 series. Because the service is provided by an RN in a facility setting (POS 22), can a professional charge be billed?

  14. Travis Mosely Says:

    I hope I can help. I am the cath lab director of a for profit facility and I am reading over this discussion, so let me see if what I have to share can be of assistance.

    CPT 99152 (being that the patient is 5 years or older) will be charged initially, once the physician is actually in the room and scrubbing into the procedure, lets say a CPT 93458 (Left Heart Cath)is being performed. A nurse, who is considered “an individual who is qualified to monitor the patient during the procedure, who has no other duties (i.e., assisting at surgery) during the procedure”, as per the ACC, must be soley tied to sedating the patient. This is not the Physician sedating the patient, that would be impossible, he is scrubbed in and should be focused on performing the angiogram.

    The RN is performing the 99152 and monitoring the patient, under the license of the performing physician, not so much under his guidance. If the procedure last more then 15 minutes after the administration of sedation, of which it will, then, for every 15 minute time increment after the initial (99152)you will charge a 99153.

    I have heard rumors that you can only charge two 99153 after the initial 99152, but I can not find anything to substantiate that claim. Hope this helps.

  15. Bonnie Says:

    Can you bill the medication or is it included?

  16. noemi rubio Says:

    I have a question on the proc code 99153 is billed in hospital and medicare denied this proc code is only billed under PART A only.
    we our cardiology group that saw this patient in the hospital. can you explain, please.

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