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tci ED Coding & Reimbursement Alert - 2006 Issue 3

READER QUESTIONS: Ensure 3 Elements for Sedation Documentation

Question: Is it mandatory for the physician to be at the patient's bedside the entire time the patient is sedated to report moderate sedation services? What documentation do payers expect from the physician?Florida SubscriberAnswer: If you are reporting sedation codes, the physician does need to be present during the sedation of the patient. In that case, the only time you can bill is the time the physician spends at the bedside. CPT uses the term -intraservice time,- which it de-fines as follows: -Intraservice time starts with the administration of the sedation agent(s), requires continuous face-to-face attendance, and...

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