Moderate sedation Denials.  How do we get paid for 99153?

Moderate sedation Denials. How do we get paid for 99153?

September 21, 2017

Question:
We are billing the new moderate sedation codes, but are getting denied on the second 15 minutes, 99153.  Almost all our patients have sedation for more than 15 minutes. What are we doing wrong?

Answer:

The answer depends on your place of service!  The codes you are referencing are listed below.  Code 99151 or 99152 are paid without a problem.  It’s code 99153 that is the issue. When Medicare valued these new codes as part of the Medicare Physician Fee Schedule, 99151 and 99152 have work and total RVU’s assigned.  Code 99153, for the second 15 minutes, (or a minimum of 23 minutes total of sedation) does not have professional work RVU value assigned; thus in a Facility setting Medicare will not pay, as there is no physician work and Incident-To does not apply in a Facility setting.   In a private practice (Non Facility)  Medicare will  pay for these additional minutes performed by the physician employed staff as Incident-To services are met assuming the physician continues to provide direct supervision.  To recap: In a Facility Setting, Medicare considers all physician work for moderate sedation to be covered by CPT codes 99151 and 99152.  In a Non Facility setting, Medicare will reimburse the private practice assuming Incident-To rules are met.

CPT Code

Description

⨀⦸99151

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 intra-service time, patient younger than 5 years of age

⨀⦸99152

initial 15 minutes of intra-service time, patient age 5 years or older

+99153

each additional 15 minutes intra-service time (List separately in addition to code for primary service)

 

*This response is based on the best information available as of 09/21/17.

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