Frequently Asked Questions About Moderate Sedation

Question: Is the physician required to be in the procedure room until the end of intra-service time? Often, our physicians leave the room while the registered nurse continues to monitor and prepare the patient for recovery.

Intra-service time for endoscopy is scope-in to scope-out, but moderate sedation intra-service time begins at the first dose IV medication and concludes when the patient is stable and can be moved to recovery, and the individual providing the sedation ends personal continuous face to-face time with the patient. Obviously the timing overlaps, however these are now considered different services so time definitions differ. 

I read the G code minimum time is 7.5 minutes compared to the 99151-99153 code being 10 minutes. Can you explain this further?  

Although the CPT descriptor says “initial 15 minutes,” the CPT Panel decided that anything less than 10 minutes of service is not reported.  Other time based codes often have the threshold to report at “halfway” (i.e., 7.5 minutes), but this service has different rules (not up to GI). 

The “initial 15 minutes” extends to 22 minutes of service before the add-on code 99153 becomes applicable for another subsequent 15 minutes. There is no published guidance, however it appears that if less than the entire subsequent 15 minutes of service is provided, then 99153 is not reported.

 

Question: CPT codes 99151-99153 are for 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. Do these CPT codes require a physician, physician assistant or nurse practitioner to actually administer the medication(s), or  can a registered nurse administer the medication(s) under the direction and supervision of the physician during the procedure?

There is no change in the manner in which moderate sedation is provided (i.e., a registered nurse can administer under the supervision of the physician performing the procedure). Only the codes used to capture the time/physician work from the initiation of the first dose to the patient being stable to leave the procedure room for recovery have been altered.

Question: Define a ‘qualified health care professional’ providing sedation?

A qualified health care professional is determined by your specific state’s regulations, as well as hospital/facility bylaws.

Question: Does a registered nurse count as a qualified health care professional?

Not for purposes of reporting moderate sedation codes.

Question: If moderate sedation is being provided in an outpatient hospital department by hospital staff, can the supervising physician bill for the service?

Moderate sedation is a part B covered service, with administration by the physician performing the procedure. Moderate sedation is not a hospital outpatient or ASC clinical staff service, so the coding/billing is done by doctor as a professional fee. It is the physician work related to moderate sedation. The registered nurse under supervision may push the drugs but that person's cost is part of facility fee.

Question: For an office setting procedure, the Medicare Physician Fee Schedule shows reimbursement is $57.04 and $5.92 at the facility location. The reimbursement rate that is being spoken about is only a few dollars even at the office location. Is that correct?

Yes, the service only has 0.10 work RVUs and this translates into very few dollars; the majority of payment in an office endoscopy setting reflects practice expense. 

Question: Do we include the time on the bill (i.e., line 19) as we have for Propofol?

Yes, you should include total time on line 19, as well as the increment for the add on code.

Question: If we were to provide Monitored Anesthesia Care (MAC) anesthesia on a Medicare patient that might have been an ASA II classification, will we still receive the professional fee paid (and just be penalized the cost of providing conscious sedation)?

Moderate Sedation (0.10 wRVUs) has been removed for the base procedure. If you bill for a colonoscopy and perform MAC beginning January 1, 2017, there will be lower physician payment than if you billed colonoscopy + G0500.

Question: A patient has an Esophagogastroduodenoscopy (EGD) and Oligomeric-Proanthocyanidins (OPC) during the same session. Two different physicians performed the procedures. Physician A performed EGD and Physician B the OPC. How do we bill for sedation? Does Physician A receive the charge, or do we split the times up between the physicians?

For coding, it is important to keep in mind that only G0500 and 99152 have physician work. These codes capture the initial 15 minutes of moderate sedation. Remaining codes (i.e., add on codes) are PE only (i.e., clinical staff, supplies, equipment). If this a commercial patient, you may want to verify with your specific payer the process to ensure proper claims processing.

Question: Provation MD has already added CPT codes related to moderate sedation. How will this impact the coding staff who also need to bill through other systems that have not yet incorporated (i.e., ASC versus in-hospital)?

The correct CPT codes and associated charges need to be loaded into whatever system is being used. Adequate information needs to be conveyed to billing to allow for proper coding.

Question: Can we charge a service fee for code G0500?

Yes, there should be a charge. It can be decided upon just as you would the charge for any physician service. Practices commonly utilize some multiple of Medicare in their fee schedule but that is an individual decision. We expect a reimbursement of about $5-$6 dollars for Medicare G0500, and about $12-$13 dollars (the national average) for 99153.

Question: Do you have a list of private insurance companies that will be implementing this new coding procedure for moderate sedation?

Non Medicare companies may or may not choose to adjust endoscopy fees and reimburse moderate sedation separately. We do not currently know if G codes will be recognized by non-Medicare payors. You should contact your major payers, review online bulletins and/or remittance advice.

Question: Should we reduce our procedure code costs to compensate for the new moderate sedation codes or is it ok to keep our 2016 fee schedule prices and bill for the new moderate sedation codes at an additional cost?

That is your decision but there is no legal necessity to reduce your fees. Most practices make periodic inflation adjustments to charges. We don’t know if private payers are going to pay attention to moderate sedation coding or reduce endoscopy fees, even though in theory they should if they follow CPT and Medicare conventions.  

Question: Will these codes be zero dollar codes? Are we expected to create a fee for each?

If you put a zero dollar, you will receive zero payment. Create a charge, get some idea of the value and what you will likely be reimbursed. You set your fees as you judge, and then see what you’re writing off. Reimbursements will likely differ between G0500 and 99152; payment for +99153 is not expected. Whether you choose to make the latter a zero fee or a fee which gets written off (billing on assignment) is up to you.

Question: How will crossover claims be handled if Medicare is primary (with a secondary insurance that rejects the crossover claims since they are not using these codes yet)?

If you have to convert a G code like G0121 or G0105 colonoscopy service to 45378 for colonoscopy secondary payment, then likely you will need to convert the G0500 moderate sedation code to 99152. Some secondary payers may recognize G codes or perform the conversion for you. The reverse would apply if Medicare is a secondary payer. 

Question: How does this affect the billing of anesthesia professionals who may be the professional administering Propofol?

The moderate sedation codes do not apply. Presently anesthesia professionals performing Monitored Anesthesia Care (i.e., deep sedation) with Propofol bill using 00740 or 00810. A new code set, however, will apply for 2018. 

Question: Our practice's CRNA’s administer our Versed and Fentanyl patients. Would we use the 99155 code?

It’s not the drug, it’s the level of sedation. If a CRNA is performing a moderate sedation level of service, then the CRNA would be billing for the moderate sedation code and receive $30-$40 dollars. The 99155 series would apply since a different individual is providing moderate sedation from the professional performing the procedure.

Question: Would an outpatient Ambulatory Surgical Center bill any of these codes?

No as these are physician professional fees rather than facility fees. The facility is paid for the IV, drug, and staff registered nurse as part of its global facility fee. 

Question: What occurs in terms of billing if either an esophagogastroduodenoscopy or colonoscopy are performed without any sedation?

Since no moderate sedation was provided, neither can be billed. The associated reduction in the procedure fee, however, will still apply.  

Question: For Medicare Advantage plans with our Independent Physician Associations (IPAs), will we need to obtain authorization for these codes when we submit authorization for the scoping?

This depends on how your IPA operates. For most cases, the answer is likely yes, or the services will not be reimbursed when submitting a claim (i.e., rejected service not being preauthorized). Most typically the authorizations will automatically include 99152 or G0500 and +99153. 

Question: What is the difference between ASC and office based endoscopy for code 99153?

Non facility total RVU comes to 0.31, versus “non-applicable” in facility. This reflects that there is practice expense (i.e., some additional staff and medication time, monitor use, oxygen, etc…) when office endoscopy extends beyond 22 minutes by “each additional 15 minutes.” 

Question: I work for a GI practice where the physicians perform procedures in ASCs as well as in-hospital. All of the anesthesia is provided by an anesthesiologist group and billed by that group. As we are not providing the anesthesia, we will not be billing any differently than we currently are for the physician. We will just see the decrease in payment based on the 0.10 RVU decrease, correct?

Yes, this is correct. The reduction of 0.10 wRVUs for Medicare for endoscopy, potentially by 0.25 RVU if 99152 is the equivalent code “adjusted for” by non-Medicare payers. 

Question: Do we use the code only per patient no matter how much of the drug is given?

Yes, G0500 as well as 99151 and 99152 are billable only once per patient encounter.

Question: Can you provide clarification on how much the Centers for Medicare and Medicaid Services (CMS) will be taking back from the providers who don't code the moderate sedation? And is that only for moderate sedation or conscious sedation? Our provider performs the conscious sedation, and when he doesn't the CRNA performs moderate sedation. If the CRNA administers the moderate sedation, will we still need to bill a 99152 code and the G code, or is it only if the provider administers?

If moderate sedation is not billed with Medicare G0500 or 99152, then Medicare removed 0.10 wRVUs (or about 2-4% of a typical endoscopy service reimbursement). Note that moderate sedation and conscious sedation are the same thing; and are differentiated from deep Monitored Anesthesia Care (deep sedation). 

You have to find out if your CRNA is providing moderate sedation or deep sedation. If the CRNA has been providing this service all along, then most likely this is deep sedation (reported by codes 00740 or 00810). If the CRNA was providing moderate sedation, then they could not have been billing for the service since this used to be inherent to the endoscopy and not separately billed. Moving forward, CRNA billing entails 99155 series codes if providing moderate sedation versus the same anesthesia codes (i.e., 00740 or 00810) if providing deep sedation.

Question: When documenting, does the physician need to document time in the notes?

Any time-based service should have the pertinent time documented, occurring within the procedure note or within the time tracker section of the Endowriter. These are the wisest locations as long as the time details can be found if there is a compliance audit. However, if billers are responsible for deciding which code(s) to apply, they will need “easy access” to the time information.

Question: Does the report need to reflect that moderate sedation was given beside the times?

Document the total time of moderate sedation per the definition and the fact that moderate sedation was provided (rather than Propofol given by an anesthesia provider); otherwise documentation is the usual endoscopy documentation.

Question: If we do use Monitored Anesthesia Care, do we need to document why we had to versus why we didn't use Moderate Sedation?

This is not a CPT issue, however, a medical necessity concern related to payer policy. It is appropriate to include this information within the endoscopy report for future reference or in case a denial needs to be appealed. This extent of documentation is not necessary in order to receive payment for moderate sedation.

Question: Is there certain wording required in a dictation to state moderate sedation was performed (i.e., monitored continuously throughout the procedure)? Or is time sufficient?

No specific wording is needed. Endoscopy reports ordinarily just indicate moderate sedation was provided and gives specifics of drugs/doses. Now, the total time spent providing and supervising moderate sedation needs to be included along with billing the relevant code(s). 

Question: Is there a location to provide a list of medicines that qualify for moderate sedation?

No. Moderate sedation is defined by the level of consciousness induced by medication, not by the substances used. It is possible to induce light or moderate sedation with Propofol. It is also possible to induce deep sedation with Versed. It isn’t the drug that determines what codes to use.

Question: Is it true that the registered nurse who gives the sedation (with his/her credentials) has to be named in the operative report?

This is not an aspect of moderate sedation billing, however most facilities do incorporate names of registered nurses, techs or anyone that had an official role during the procedure. Nursing notes are most common, however, this information can also be contained within the endoscopy documentation.