What to look for when auditing moderate sedation codes 99151-99153

December 20th, 2019 - Namas
0 Votes - Sign in to vote or comment.

What to look for when auditing moderate sedation codes 99151-99153
Physicians performing diagnostic and therapeutic procedures can now separately bill for the provision of moderate sedation services, but there are some interesting wrinkles to be looking for when auditing these services.
Starting in 2017, moderate sedation codes 99151-99157 were created to address moderate (also called "conscious") sedation services when provided by either the rendering provider or a different provider. When reviewing these codes, there are some common elements to seek in the documentation, most notably the time.
The base codes 99151 and 99152 for moderate sedation by the rendering provider are for the first 15 minutes, split by patient age (99151 for those under age 5) (99152 for those ages 5 and older). Add-on code 99153 is for each additional 15-minute interval. Codes 99155 and 99156 have the same age-based split (under age 5/age 5 and over), with 99157 for each additional 15-minute interval.
 
Both code sets use the traditional approach to counting time, where units of seven minutes or less are not billed, but units of eight minutes and more are rounded up to the next unit of time. However, at that point the similarities end. Codes 99155-99157, as they describe moderate sedation performed by a different provider, deliver RVUs and payment to that provider, with the charge and documentation for that provider.
 
CPT codes 99151-99153 work a little differently. First, these codes require the presence of an independent, trained observer to assist in monitoring the patient's level of consciousness and physiological status. The name and credentials of this monitor must be documented in the medical record.
 
Because there is an independent monitor present, the codes pay considerably less to the billing physician than in cases where a different provider is rendering the moderate sedation services. In addition, from a work value perspective, Medicare has no physician work assigned to the add-on code, because from Medicare's perspective, the physician work is in the initial code that establishes the moderate sedation and the work then pivots to the independent monitor.
 
As a result, when moderate sedation is done in a facility setting - as it often is, during cardiac catheterization and other services - the physician will not be paid for the add-on code because there is no physician work, and the practice expense and other costs are borne by the facility. It's something to remember when billing these services. When done in the office, there will be practice expense payments that accrue to the group.

 

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

Billing for Telemedicine in Chiropractic
January 14th, 2020 - Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP
Many large private payers recognize the potential cost savings and improved health outcomes that telemedicine can help achieve, therefore they are often willing to cover it. While there are several considerations, there could be certain circumstances where telemedicine might apply to chiropractic care.
Non-Surgical Periodontal Treatment
January 14th, 2020 - Christine Taxin
AAP treatment guidelines stress that periodontal health should be achieved in the least invasive and most cost-effective manner. This is often accomplished through non-surgical periodontal treatment.Non-surgical periodontal treatment does have its limitations. When it does not achieve periodontal health, surgery may be indicated to restore periodontal health.SCALING AND ROOT PLANINGScaling ...
Q/A: Can Chiropractors Bill 99211?
January 14th, 2020 - Wyn Staheli, Director of Research
Can chiropractic offices bill code 99211? Technically it can be used by chiropractors, but in most instances, it is discouraged. Considering that 99211 is a low complexity examination for an established patient, this code is not really made for the physician to use. In fact, in 2021, changes are coming for this code...
Denials due to MUE Usage - This May be Why!
January 7th, 2020 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
CMS assigns Medically Unlikely Edits (MUE's) for HCPCS/CPT codes, although not every code has an MUE. MUE edits are used to limit tests and treatments provided to a Medicare patient for a single date of service or for a single line item on a claim form. It is important to understand MUE's are ...
CMS Report on QPP Shows Increasing Involvement
January 6th, 2020 - Wyn Staheli, Director of Research
MIPS 2018 participation increased according to the final report issued by CMS on January 6, 2020.
CPT 2020 Changes to Psychiatry Services
January 3rd, 2020 - Namas
As of January 1, 2020, CPT made changes to the health and behavior assessment and intervention codes (96150-96155) and therapeutic interventions that focus on cognitive function (97127). If you code and audit services in this category, you must pay close attention to the changes as they include the removal and ...
Medicare Changes Bilateral Reporting Rules for Certain Supplies
December 30th, 2019 - Wyn Staheli, Director of Research
DME suppliers must bill bilateral supplies with modifiers RT and LT on separate claim lines or they are being rejected.



About Codapedia by innoviHealth Contact Us Terms of Use Privacy Policy Advertise with Us

innoviHealth - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2020 innoviHealth Systems, Inc. - CPT® copyright American Medical Association