CPT Coding Guidelines Review: Moderate (Conscious) Sedation

This is a series of blogs about the importance of being familiar with CPT coding guidelines. Often there is extensive guidance preceding a subsection or range of codes for particular procedures, but coders are very busy so sometimes they jump right into the codes without taking time to review these guidelines, even though following or not following their direction could significantly affect the accuracy and comprehensiveness of coding.

This series is designed to help you become familiar with guidelines for significant procedures that you might not be acquainted with but do impact coding. The presentations are short and meant to generate awareness of the guidelines that are available in CPT rather than the application of guidelines to specific coding scenarios.

This installment of the series explores the guidelines related to CPT coding for moderate (conscious) sedation.

CPT Guidelines Moderate (Conscious) Sedation

Please watch this presentation to learn about the guidelines that provide direction in assigning CPT codes for moderate (conscious) sedation.

Take Aways

• The work reported with codes 99151-99157 includes:
  • Preservice work
  • Intraservice work
  • Postservice work
• Code selection is based on the provision of intraservice work alone, based on increments of 15 minutes
• Pre and Postservice work activities are not separately reportable
• Codes 99151-99157 are not used to report
  • Pain control
  • Minimal sedation
  • Deep sedation
  • Monitored anesthesia care
• If a physician or other QHP is both performing the procedure and providing the sedation service an independent, trained observer must be present to monitor the patient
• Units of intraservice time are calculated based on ranges of time

Test Your Knowledge

For detailed explanations of the quiz answers, please refer to the end of this blog post.

To find additional instruction in coding for anesthesia, explore the course Anesthesia Services on HIAlearn.com. 

Additional Coding Education: Invest in You!

Be sure to watch for other installments of CPT Coding Guidelines Review and visit HIAlearn.com to explore other educational products designed to help coders be their best! Subscribe to our YouTube channel to be notified when the next video is live.

Quiz Answers and Rationale

Question 1: The answer is completion of a pre-sedation assessment form. Completion of a pre-sedation assessment form is part of the preservice work for administering conscious sedation. All other options are included in intraservice or postservice work.

Question 2: The answer is 1 regular unit and 2 add-on units. Based on the table in CPT, 45 minutes of intraservice work for conscious sedation is reported with one unit of regular time (99151/99152) plus 2 two add-on units of 99153.

Since 1992, HIA has been the leading provider of compliance audits, coding support services and clinical documentation audit services for hospitals, ambulatory surgery centers, physician groups and other healthcare entities. HIA offers PRN support as well as total outsource support.

The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.