January 9th, 2018
Moderate (Conscious) sedation is a drug-induced state of relaxation in which the patient is typically awake and can respond to verbal commands, but might not be able to speak. A combination of medicines is used and often include a sedative as well as an anesthetic (e.g., Propofol, Versed) to block pain and even the block the memory of the procedure itself.
The CPT codebook has extensive guidelines for reporting these codes which include definitions for pre-service work, intra-service work, and post-service work. See FindACode.com or a CPT codebook for these guidelines
The "Conscious Sedation Coding Table" has two columns for providers. The "Provider who performs the procedure" means that the provider performing the procedure is the one that is also performing the conscious sedation. If the sedation is provided by another provider who does NOT perform the procedure, then report a code from the "Different Provider" column.
|Conscious Sedation Coding Table|
|Total Sedation Intra-Service Time||Provider Who Performs Procedure||Different Provider|
|Patient < 5 yrs||Patient > 5 yrs||Patient < 5 yrs||Patient > 5 yrs|
|23-37 min||99151 + 99153 X 1||99152 + 99153 X 1||99155 + 99157 X 1||99156 + 99157 X 1|
|38-52 min||99151 + 99153 X 2||99152 + 99153 X 2||99155 + 99157 X 2||99156 + 99157 X 2|
(53 min to 1 hr 7 min)
|99151 + 99153 X 3||99152 + 99153 X 3||99155 + 99157 X 3||99156 + 99157 X 3|
(1 hr 8 min to 1 hr 22 min)
|99151 + 99153 X 4||99152 + 99153 X 4||99155 + 99157 X 4||99156 + 99157 X 4|
|83 min or longer||add 99153||add 99153||add 99157||add 99157|
- Do not report sedation services of less than 10 minutes.
- When the provider performing the surgery is also performing conscious sedation, a trained observer must be present during the procedure to monitor the patient’s level of consciousness and physiological status. Periodically throughout the procedure, this observer should document sedation time and patient status/vitals. If needed, the observer’s documentation can be submitted as evidence that the guidelines were followed.