Moderate Sedation Administration Documentation and Compensation

Many fast food restaurants sell combo meals that include a drink, a burger, and an order of fries. When customers buy the combo meal, they get the food for quite a bit less than if the same items were bought separately. Electrophysiology and cardiac rhythm management device procedures have been bundled into similar packages. The package of services reimburses less than its components would if they were billed separately.

For example, 33228 is the code for a dual-chamber pacemaker generator changeout. It includes removing the old generator and inserting a new one. It secures 5.52 work relative value units (wRVUs) for the operator. 

The surgical components of a generator changeout are generator extraction 33233 (3.14 wRVUs) and generator insertion (5.28 wRVUs). If it were acceptable to bill these two codes together, which it’s not, the lesser of the two would be reduced by 50% due to the multiple procedure payment reduction. Therefore, the sum wRVUs for billing the surgical components separately would be 6.85 ([3.14/2] + 5.28). By bundling these components into a package, Medicare secures a discount of 1.33 wRVUs. That’s 19.4%!

The device surgery combo deal is even better. That is because in addition to the surgical services, it includes certain patient visits that take place within the global period. The global period for device procedures includes the day of the implant, the day before the implant, and 90 days after the implant. A preoperative history and physical (H&P), a hospital discharge, and an incisional site check are all compensated by the 5.52 wRVUs paid for the generator change (33228). 

Until recently, the package deal also included the administration of moderate sedation. 

In the Proposed 2017 Physician Fee Schedule, Medicare stated, “practice patterns for endoscopic procedures were changing, with anesthesia increasingly being separately reported for these procedures.” Medicare’s concern with this is that when one provider bills for sedation in addition to what the gastroenterologist bills, payment is made twice for moderate sedation. Rather than revaluing the individual endoscopic codes to adjust for this, Medicare chose to carve moderate sedation out of all 400+ procedures that it was previously bundled into.

Implantable loop recorder surgeries, pacemaker surgeries, defibrillator surgeries, EP studies, ablations, cardioversions (internal and external), and transesophageal echocardiography were all impacted. Because of this, electrophysiologists will forfeit at least 0.25 wRVUs per procedure if they don’t bill for moderate sedation.  

New codes that became effective on January 1st, 2017 should be used to report moderate sedation. The new codes are differentiated in a few ways:

• One set of codes is appropriate for moderate sedation administered by the physician performing the surgical procedure (99151 – 99153). Another set is to be reported by a provider administering moderate sedation when another physician is performing the surgical procedure (99155 – 99157).
• The first two codes in each range should be used to report the first 15 minutes of moderate sedation. Codes 99152 and 99156 will be the most common because they are appropriate for patients who are 5 years of age or older. Codes 99151 and 99155 are only applicable for patients who are less than 5 years old.
• The last codes in each range, 99153 and 99157, appear to be appropriate for reporting each additional 15 minutes of moderate sedation. Later in this article, we will explore a problem with code 99153.

Because moderate sedation will be reported separately, it is important to make sure that operative reports contain all the information needed to satisfy the definition of the code reported. Don’t forget the Compliance Department mantra: “If it’s not documented, it didn’t happen.” Your mastery of moderate sedation documentation will be enhanced by keeping that mantra in mind while reviewing the definitions below:

• 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 years or older.
• 99153 - 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; each additional 15 minutes intraservice time (List separately in addition to code for primary service). 
• 99156 - Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient age 5 years or older.
• 99157 - Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes intraservice time (List separately in addition to code for primary service). 

The ideal operative report contains a statement establishing: (1) the physician performing the surgery administered moderate sedation; (2) the presence of an independent trained observer; and (3) how long the moderate sedation was administered. These requirements are defined as follows:

1. How CPT 2017 describes the administration of moderate sedation: “Supervise and direct an independent trained observer who will assist in monitoring the patient’s level of consciousness and physiological status throughout the procedure.” 
2. How CPT 2017 defines an independent trained observer: “An independent trained observer is an individual who is qualified to monitor the patient during the procedure, who has no other duties (e.g., assisting at surgery) during the procedure.”
3. According to CPT, moderate sedation time: “Begins with the administration of the sedating agent(s); ends when the procedure is completed, the patient is stable for recovery status, and the physician or other qualified health care professional providing the sedation ends personal continuous face-to-face time with the patient.”

Therefore, this is an example of an acceptable statement: “I administered moderate sedation throughout this 45-minute procedure. An independent trained observer pushed medications at my direction, and monitored the patient’s level of consciousness and physiological status throughout.”

Note how this statement doesn’t say that the independent trained observer “administered” medications. An auditor might interpret that to mean that the independent trained observer administered moderate sedation rather than the physician. The word can be used multiple ways; it’s best to use it in the way that will most definitively support what is being reported. 

CPT instructions establish that 10 minutes must be spent administering moderate sedation before reporting either of the codes specific to the initial 15 minutes of sedation. Code 99152 should be used if moderate sedation is administered by the operator. Use code 99156 if it is administered by another billing provider, such as another physician or mid-level provider. 

The full 15 minutes associated with the base code must be satisfied, then 8 additional minutes must be spent administering moderate sedation to qualify for the “each additional 15-minute” codes. Code 99153 is applicable when the physician performing the procedure administers moderate sedation, and code 99157 should be used when a different provider administers sedation. Each 15-minute block of time reported with code 99157 will generate 1.25 wRVUs. 

Earlier in this article, I alluded to a concern with code 99153. This concern is outlined in the 2017 Medicare Physician Fee Schedule, which states that CPT code 99153 is a “PE-only code”. This means that code 99153 does not secure any additional wRVUs for the physician performing the procedure — only practice and malpractice expense RVUs are assigned to it. Because of this, physicians will secure wRVUs for the first 15 minutes of administration (99152), but not for any time more than that.  

Medicare has assigned 0.25 wRVUs to code 99152. The same amount was carved out from all but 6 of the EP/CRM-related codes on the moderate sedation list. The exceptions are mapping (93609 and 93613), LA pacing and recording (93621), LV pacing and recording (93622), and the add-on codes for additional ablations performed after SVT, VT, or AF ablations (93655 and 93657). Each of these 6 codes is on the moderate sedation list, but no wRVUs have been deducted from them. This makes sense because each of these codes can only be reported in addition to one of the other codes that is having wRVUs carved out. 

For most procedures, the amount paid for moderate sedation will add up to the same amount that was carved out. But for some procedures, the physician will lose wRVUs. This is because some procedures are reported with more than one of the surgical codes from which wRVUs were carved out. 

For example, if a provider bills for an ICD implant (33249) and for defibrillation threshold testing (93641), he will forfeit 0.25 wRVUs for each code — a total of 0.5 wRVUs. Only the first 15 minutes of moderate sedation are compensated. For this, the provider will receive 0.25 wRVUs. The moderate sedation adjustments cost the provider 0.25 wRVUs. The same reduction will happen when doctors remove electrodes, relocate skin pockets, and repair electrodes at the time of a device surgery.

In the proposed rule, Medicare stated, “When moderate sedation is reported for Medicare beneficiaries, we expect that it would most frequently be reported using the code that describes moderate sedation furnished by the same person who also performs the primary procedure.” 

In those cases where it is administered by a different provider, the first 15 minutes generates 1.65 wRVUs and each additional 15 minutes generates 1.25 wRVUs. At these rates, moderate sedation for a one-hour procedure is rewarded with 5.4 wRVUs. 

At almost 22 times the reimbursement for sedation administered by the operator, sedation administered by someone other than the operator is quite lucrative. For some procedures, a provider administering moderate sedation will receive more wRVUs than the operator. Because there is such a big upcharge for sedation provided by someone else, make sure to clearly document the medical necessity for it when it is indicated. Logical reasons include the unavailability of a dedicated trained observer and procedural complexity that precludes the EP from concurrently administering moderate sedation. Documentation is the key.

Jim Collins, CPC, CCC is a consultant at CardiologyCoder.Com, Inc. He provides annual audits of documentation and coding, optimizes device clinics, and works with multiple billing companies to offer the optimal revenue cycle management solution for any cardiology group or service line. He is a Certified Professional Coder, a Certified Cardiology Coder, and he regularly tweets about reimbursement under the Twitter handle @CardiologyCoder. Jim can be reached at 518.320.4376 or Jim@CardiologyCoder.Com.