Moderate Conscious Sedation Frequently Asked Questions

Moderate (Conscious) Sedation [MCS], is a drug induced depression of consciousness. The patient maintains the ability to respond purposely to verbal direction or verbal direction either alone or accompanied by light tactile stimulation. Interventions are not required to maintain the patient’s airway.

According to CPT, Moderate (Conscious) Sedation includes:
Assessment of the patient, establishment of IV access, administration of agent(s), maintenance of sedation, monitoring of oxygen saturation, heart rate, and blood pressure, and recovery.

CPT Code 99143 describes Moderate Sedation provided by the same physician performing the diagnostic or therapeutic service that the sedation supports for patients younger than 5 years of age for the first 30 minutes of intraservice time.
CPT Code 99144 describes Moderate Sedation provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, for patients 5 years of age or older for the first 30 minutes of intraservice time.
CPT Code 99145 describes each additional 15 minutes of intraservice time.

Codes 99143-99145 describe Moderate (Conscious) Sedation services provided by the same physician who is also performing the procedure or diagnostic service for which the Moderate (Conscious) Sedation is needed. Codes 99148-99150 describe Moderate Sedation services provided by a physician other than the health care provider performing the diagnostic or therapeutic service for which the MCS is needed. Both sets of codes are then further delineated based on patient age and incremental time, as shown in FAQ 4.
CPT Code 99148 describes Moderate Sedation provided by a physician, other than the health care professional performing the diagnostic or therapeutic service that the sedation supports, for patients under 5 years of age, for the first 30 minutes of intraservice time.
CPT Code 99149 describes Moderate Sedation provided by a physician, other than the health care professional performing the diagnostic or therapeutic service that the sedation supports, for patients age 5 years of age or older, for the first 30 minutes of intraservice time.
CPT Code 99150 describes each additional 15 minutes of intraservice time.

The intraservice time should be clearly documented in the ED chart. For these codes, as described by CPT Assistant (February 2006), “Intraservice time starts with the administration of the sedation agent(s), requires continuous face-to-face attendance, and ends at the conclusion of personal contact by the physician providing the sedation.” The patient needs to be continuously monitored and reassessed. An independent, trained observer must be present to assist in monitoring the patient when the physician is both performing the procedure and providing the MCS.
Repeat assessment of the patient and recovery, once personal contact is concluded, are not included in intraservice time. The total time of patient recovery will typically be documented in the nursing section of the patient record, but is not necessary in the physician note.

In October 2011 CPT Assistant indicated that the CPT standard for time measure does apply to the moderate (conscious) sedation codes 99143-99145 and 99148-99150. Per CPT, A unit of time is attained when the midpoint has been passed. For example, an hour is attained when 31 minutes have elapsed (more than midway between zero and sixty minutes).
Moderate sedation is a time-based code. Because the Moderate Sedation codes indicate a unit of time of 30 minutes, the ED chart must indicate 16 minutes or more of intraservice time to report Moderate Sedation. If the time threshold has not been met, then the code is not reportable.

No. In 2012, CPT indicated that when using codes 99143-99145, it is understood the physician will be performing a diagnostic/therapeutic procedure at the same time. There is no need to subtract the procedure time from the Moderate Sedation time.

To meet the CPT requirement of “A unit of time is attained when the midpoint has been passed” a total time of more than 37.5 minutes of intraservice time must be documented. (Per CPT ASSISTANT, October 2011).

In reporting MCS, the following services are included and are not reported separately:
•Assessment of the patient (not included in intraservice time);
•Establishment of IV access and fluids to maintain patency, when performed;
•Administration of agent(s);
•Maintenance of sedation;
•Monitoring of oxygen saturation, heart rate and blood pressure; and
•Recovery (not included in intraservice time)

CPT considers Moderate (Conscious) Sedation to be an inherent part of a number of procedures. This means that the physician who is performing both the procedure and providing the MCS may not separately report the MCS codes since it is bundled with the procedure. These procedures are listed in Appendix G of the CPT codebook. CPT listed 321 procedures codes with the 2012 Appendix G. Codes bundling MCS are denoted with a target symbol in the CPT book. CPT further instructs, in the circumstances when the patient does not require sedation, the operating physician is not required to report the procedure as a reduced service-using modifier 52.
Codes of interest to emergency medicine bundling Moderate (Conscious) Sedation include the following:
31615- tracheobronchoscopy through tracheostomy
31622- bronchoscopy diagnostic
32551- chest tube insertion
33010- pericardiocentesis
33210- insertion transvenous pacemaker
36555- insertion pediatric (under age 5) central line
36568- insertion pediatric (under age 5) PICC line
92953- transcutaneous pacing
92960- elective cardioversion
Do not report codes 99143-99145 with procedures listed in Appendix G.

When the Moderate (Conscious) Sedation services are provided in the Emergency Department setting, by a second physician in support of a procedure listed in Appendix G, the moderate sedation service codes 99148-99150 may be reported.

The MCS services described by codes 99143-99145 require the presence of an independent trained observer to assist in the monitoring of the of the patient’s level of consciousness and physiologic status.
Unlike the previous Conscious Sedation codes, the new MCS codes include all of the six possible routes of administration (intramuscular, intravenous, oral, rectal, intranasal, and inhalation).
Documentation should include the name of the procedure, medication names, dosages and routes of administration, who administered the medication(s) (physician or observer), notations of ongoing assessments and vital signs monitoring during MCS. Documentation of this by nursing in a separate area of the chart does not need to be copied into the physician’s chart.

National Medicare has reconsidered its payment policy on Moderate (Conscious) Sedation. For 2009, the codes have been assigned a Status Indicator C, meaning they are carrier priced, and do not carry an assigned RVU. Regional Medicare carriers are being encouraged by National CMS to recognize Moderate Sedation services.
For more detail, see CMS Transmittal 1324.

Note:

Reflex withdrawal from a painful stimulus is NOT considered a purposeful response.

Providers of deep sedation/analgesia must be prepared to “rescue” from general anesthesia.

Deep sedation will be performed in appropriate settings only by providers credentialed to provide general anesthesia.

General anesthesia is the induction of a state of unconsciousness with the absence of pain sensation over the entire body, the administration of an ascetic drugs. It is used during certain medical and surgical procedures and may include.

The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired. General anesthesia will be performed by credentialed anesthesia providers under the standards of anesthesia care.

The American College of Emergency Physicians (ACEP) has developed the Reimbursement & Coding FAQs and Pearls for informational purposes only.   The FAQs and Pearls have been developed by sources knowledgeable in their fields, reviewed by a committee, and are intended to describe current coding practice. However, ACEP cannot guarantee that the information contained in the FAQs and Pearls is in every respect accurate, complete, or up to date. The FAQs and Pearls are provided “as is” without warranty of any kind, either express or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. Payment policies can vary from payer to payer. ACEP, its committee members, authors or editors assume no responsibility for, and expressly disclaim liability for, damages of any kind arising out of or relating to any use, non-use, interpretation of, or reliance on information contained or not contained in the FAQs and Pearls. In no event shall ACEP be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. Specific coding or payment related issues should be directed to the payer. For information about this FAQ/ Pearl, or to provide feedback, please contact David A. McKenzie, CAE, Reimbursement Director, ACEP at (972) 550-0911, Ext. 3233 or dmckenzie@acep.org.

Updated 05/26/2015