Moderate Sedation Time:
New Clarification Raises Concern
By Justin Vaughn, M.Div, CPC
Director of Compliance

10/14/2011

The American Medical Association (AMA) has responded to an inquiry from healthcare attorney David Vaughn regarding the threshold that must be met—in minutes—for billing the moderate sedation codes (99143-99150).  In an official and binding response from its research division, CPT Knowledge Base, the AMA advised that:
“. . . the new Time guidelines in the Introduction to CPT do apply to the moderate (conscious) sedation codes 99143-99145 and 99148-99150. As there are no code or code-range-specific reporting instructions in the guidelines, parenthetical instructions, or code descriptors to the contrary, the new Time guidelines are indeed applicable to the moderate (conscious) sedation codes.”

So, what are the CPT time guidelines?  Simply put, they mandate that “a unit of time is attained when the mid-point is passed.”  Therefore, for a time-based code, such as 99144 (moderate sedation, 5 years of age or older, first 30 minutes), you must provide the service for at least 16 minutes in order to bill that code.

What this means in the practical, every-day world of the pain practitioner is that your ability to bill for moderate sedation in addition to the pain injection will dramatically diminish since many, if not most, injection procedures take less than 16 minutes.  Remember also that this is not a Medicare-specific rule, but rather a CPT coding rule, and thus applies across the full spectrum of healthcare payors. 

Based on the above, Medac urges all its clients who wish to submit claims for moderate sedation to list the number of minutes the sedation service was provided in the documentation it sends to the billing office.  If the number of minutes is less than 16, we will not bill the sedation service.  If the number of minutes is missing in your documentation, we will not bill the sedation service.  Obviously, the worst thing a provider could do in response to this new rule is to fudge the number of minutes just to reach the 16-minute threshold.  Auditors and U.S. Attorneys always find a way to ferret out the truth.  The best policy is to always document your moderate sedation time, and to do so in exact minutes.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.