Changes to CPT coding for sedation

May 8th, 2017 / By Rebecca Caux-Harry

The CPT changes for 2017 brought a surprise, at least for me. You may have noticed a trend over the last several years of consolidation within the codeset. When two codes are routinely reported together, the AMA has looked at changing the rules to reduce administrative burden, so that a single code will now report the entire service. This year’s update, however, included the unbundling of conscious sedation. New codes 99151-99157 can be reported when moderate/conscious sedation is provided. The codes are time and age based and depend upon whether the sedation is provided by the same provider performing the procedure. For example: 

99152 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 age 5 or older.

Add-on codes are available for each additional 15 minutes, codes 99153 and 99157.

The previous moderate sedations codes, 99143-99150, have been deleted. Notice that the deleted codes were for 30-minute increments whereas the new codes are for 15 minute increments. In addition to the new and deleted code changes for this year, the target icon (◉) was removed, which previously indicated that moderate sedation was bundled with the procedure code, making it one of the most common deletions, occurring over 400 times in the update of Category I codes. The icon has also been removed from multiple Category III codes as well.

The new moderate sedation codes are professional only, meaning the -26 or -TC modifier don’t apply. However, there is one exception,

99153 Moderate sedation…each additional 15 minutes intraservice time (list separately in addition to code for primary service).   

This code is technical only and has no Work Relative Value Units (RVUs). One CMS contractor clarified that this code represents additional time provided by a nurse or other personnel employed by the hospital and that the provider would be engaged in performing the procedure rather than monitoring the patient’s consciousness level. The nurse or other healthcare professional would be an employee of the hospital and this service does not qualify for Incident-to coding. Therefore no additional payment to the provider is made. You can decide whether to report this code based on internal tracking needs, but don’t waste time fighting the denial. CMS will not reimburse this code for professional services.

When coding procedures, make sure to reference your coding tools if the provider has documented moderate sedation. The codes impacted by this change are primarily percutaneous procedures, where general anesthesia is rare, and are most common in the surgery section.  But, there are several 90000 codes also impacted. Additionally, if your providers are unaware, make sure to speak with them regarding documentation of moderate sedation services provided and the time spent.  The reimbursement for these codes isn’t high, but the service was performed and should be reported. Don’t leave rightful reimbursement on the table. Happy coding!

Rebecca Caux-Harry, CPC, is the CodeRyte product specialist for cardiology with 3M Health Information Systems.