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The Coding Institute, Coding Tips: Coders and providers often have misconceptions about coding for moderate sedation, also known as conscious or twilight sedation. First of all, let’s define moderate sedation. From an awareness standpoint for the patient, moderate sedation is a depressed level of consciousness. Patients who have moderate sedation along with analgesic agents should be relatively pain free during the procedure, as well as calm, tranquil, and unable to remember the procedure. What’s the advantage of moderate sedation over other types of anesthesia, such as general? With moderate anesthesia, patients can still maintain a patent airway — that is, their tracheas remain open — as well as respond appropriately to both physical stimulation and verbal commands. Let’s bust some myths about anesthesia coding and moderate sedation.
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The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713, Eenterprise Contact: Sam Nair, Direct: 704 303 8150,
Learn the A-B-ZZZs of Reporting Moderate
Sedation By Susan Dooley
Coders and providers often have misconceptions about coding for moderate sedation, also known as
conscious or twilight sedation. First of all, let’s define moderate sedation. From an awareness standpoint
for the patient, moderate sedation is a depressed level of consciousness. Patients who have moderate
sedation along with analgesic agents should be relatively pain free during the procedure, as well as calm,
tranquil, and unable to remember the procedure. What’s the advantage of moderate sedation over
other types of anesthesia, such as general? With moderate anesthesia, patients can still maintain a
The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713, Eenterprise Contact: Sam Nair, Direct: 704 303 8150,
patent airway — that is, their tracheas remain open — as well as respond appropriately to both physical
stimulation and verbal commands. Let’s bust some myths about anesthesia coding and moderate
sedation.
Myth 1: Sedation is Sedation is Sedation
Actually, it’s not. According to the American Society of Anesthesiologists (ASA), sedation comes in four
levels: Minimal, moderate, deep, and general. We’ve already talked about moderate sedation, which is
often used for procedures such as esophagogastroduodenoscopy and colonoscopy. Minimal sedation is
also sometimes called anxiolysis, which means anxiety reducing; this is a drug-induced relief of
apprehension with only minimal effect on consciousness and sensation.
With deep sedation, consciousness is depressed to the point that the patient cannot be aroused;
however, he or she can respond to painful or repeated stimuli. Unlike with minimal and moderate
sedation, with deep sedation patients may not be able to maintain their own airways or breathe on their
own. General anesthesia is the fourth type of sedation: This is a state of unconsciousness, one where
the autonomic nervous system cannot respond to surgical or procedural stimuli.
Myth 2: Only Anesthesiologists Perform Moderate Sedation
No again — in fact, CPT®’s section of moderate sedation codes was reworked a few years back to allow
reporting of cases where non-anesthesiologist physicians sedate patients. (Specifically, these are
moderate sedation codes 99143-+99145, for sedation performed by the same provider who performs
the procedure.)
If your physician administers moderate anesthesia before she performs an injection or nerve block for
therapeutic services, you can report a moderate anesthesia code along with the procedure code. To see
services that cannot be reported with a separate moderate sedation code, check CPT® codes for a “bull’s
eye” symbol. These procedures are also listed in Appendix G of the CPT® Manual.
Myth 3: Providers Can Monitor Sedation While Doing the Procedure
Nope! Moderate anesthesia requires an independent trained observer to assist in monitoring the
patient’s status while the procedure is ongoing to ensure patient safety. This means that even if the
provider is a trained anesthesiologist acting as surgeon to administer a nerve block, for example, that
anesthesiologist must have a trained independent observer, such as a registered nurse with Basic Life
Support (BLS) or Advanced Cardiac Life Support (ACLS) certification. That observer must be fully
dedicated to monitoring the patient, administering drugs, and recording what happens during the
sedation period. The moderate sedation codes specifically state this in their descriptors.
What About You?
Do you have any tips to share about anesthesiology coding? Let us know.
The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713, Eenterprise Contact: Sam Nair, Direct: 704 303 8150,
Keep Up With Changes in Coding With Anesthesia Coding Alert!
From helping you stay up to date on performance measures to pointing out easy-to-miss differences in
descriptors, Anesthesia Coding Alert keeps you covered. You’ll uncover new anesthesia coding
opportunities to keep your practice’s reimbursements flowing. You can search thousands of archived
anesthesia coding articles — going all the way back to 1999! — by code or keyword to find the info you
need in a flash. Contact us for your free sample today!
Contact Us:
Name: Sam Nair
Title: Associate Director
Email: [email protected]
Direct: 704 303 8150
Desk: 866 228 9252, Ext: 4813
The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713
