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

July 27, 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:
You are doing nothing wrong!  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, 99152 (or G0500 for GI endoscopy procedures) had an RVU assigned.  Code 99153, for the second 15 minutes, (or a minimum of 23 minutes total of sedation) did not have a professional fee value assigned, indicating that Medicare will not pay for these additional minutes. Medicare considers all physician work for moderate sedation to be covered by the single code; 99151 (or G0500 for GI endoscopy procedures). Continue to bill per CPT guidelines that allow this second code. Private payors may pay for this code. Write off the Medicare denial.

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)

  G0500

Moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that 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 age 5 years or older. Report additional time with 99153 as appropriate

Use only for GI endoscopy procedures for Medicare patients

 

*This response is based on the best information available as of 07/27/17.

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