Moderate Sedation: AMA Clarifies Billable Time

-->September 15, 2012Billing & Compliance Alerts

    Moderate Sedation:
    AMA Clarifies Billable Time

    By Justin Vaughn, M.Div, CPC

    As many of you know, pain physicians may, under certain circumstances, bill moderate sedation in addition to the therapeutic procedure itself. The typical code reflecting such service is CPT 99144, the descriptor of which states (in pertinent part):  “first 30 minutes intra-service time.”  According to a 2011 clarification by the AMA—which we concurrently brought to your attention—a physician must perform a service for greater than half the time period specified in the code descriptor in order for that service to be billable.  Accordingly, a provider would need to spend at least 16 minutes performing moderate sedation in order to submit a claim for that service.

    This 2011 guidance from the AMA seemed clear enough; however, some wondered if the doctor’s presence with the patient through the recovery process could count toward the 16-minute threshold.  This prompted a further inquiry to, and clarification from, the AMA.  In a September 2012 email to healthcare attorney David Vaughn, the CPT KnowledgeBase—the research arm of the AMA—asserted that “recovery . . . is NOT reported separately.”  Indeed, the 2012 CPT manual itself stipulates in the introductory notes of the Moderate Sedation section that recovery is not included in the intra-service time.

    Based on the AMA’s position, as promulgated by its research agency and its CPT manual, pain physicians should not count the minutes spent with the patient in recovery as part of their total moderate sedation time.  Unfortunately, this will mean that many providers will find it much more difficult to meet the time criteria necessary to bill CPT 99144.

    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in the health care regulatory and compliance environments, the author’s presentation of this information might become outdated.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.