tci Outpatient Facility Coding Alert - 2018 Issue 6

Reader Question: Know CPT® Guidelines on Reporting Moderate Sedation Administration

Question: I have two patients (over 5 years of age) receiving moderate sedation. One receives just 4 total minutes and the other receives 25 total minutes. Both are administered by the same provider as the procedure. How do I code each case, respectively? New Jersey Subscriber Answer: With respect to the first case, you may not submit a moderate sedation code in addition to the procedure code. CPT® states that the physician must report at least 10 minutes of intra-service time in order to report the initial moderate sedation code. Any time administering moderate sedation below the 10-minute mark...

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