AHA Coding Clinic® for HCPCS - 2012 Issue 3

Reporting Moderate (Conscious) Sedation

We have received inquiries regarding how to correctly report moderate (conscious) sedation with procedures and/or services provided. But, what is moderate (conscious) sedation? The Centers for Medicare and Medicaid Services (CMS) defines conscious sedation as (Transmittal 59 dated May 21, 2010): “Moderate (conscious) sedation is a drug induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.” Under CPT coding guidelines, moderate (conscious) sedation services are distinct from...

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