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How to become Perfect in Coding Moderate Conscious Sedation

As I have already shared previously there have been lot of changes in CPT codes in 2017. Also, we have new CPT codes for moderate conscious sedation as well in 2017. Since, the conscious sedation service is now removed from almost all the surgery codes, it will now be mandatory to code sedation separately when it is documented. So, the new CPT codes 99151, 99152, 99153, 99155, 99156 and 99157 will be used from 2017 for coding moderate conscious sedation. You will notice that all the codes which use to include conscious sedation will be now a revised code. This is because the sedation has been removed from all these CPT code and the codes description has been revised.

How to become Perfect in Coding Moderate Conscious Sedation

When to code Moderate conscious sedation

Their might be confusion regarding how to know about moderate conscious sedation in document and which code should be reported. Being a surgery coder, I have faced few difficulties in the beginning for coding moderate sedation especially for calculating the time. But, now it is easy process for me. You just have to see the documentation of moderate conscious sedation in the medical report. Yes, whatever documented in the report should be coded. Now for example, a biopsy report of a 50-year-old patient documents moderate sedation of 30 minutes under the monitor of radiology nurse. This report should be coded with moderate sedation CPT code as 99152 and 99153. This way you can easily become perfect in coding moderate conscious sedation services.

Read also: Learn about the new CPT codes for Spinal injection 62320-62326 in 2017

Sample Coded report for Moderate Conscious Sedation

CT/CT BIOPSY CORE BONE DEEP

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CLINICAL DATA:  71-year-old male with a history of prostate cancer and lung cancer. He has been referred for biopsy of left femur lesion.

MEDICATIONS AND MEDICAL HISTORY:

Versed 2.0 mg, Fentanyl 100 mcg.

Additional Medications: None.

The patient’s level of consciousness and physiologic status monitored by Radiology Nursing.

 ANESTHESIA/SEDATION:

Moderate sedation time: 17 minutes

PROCEDURE: The procedure, risks, benefits, and alternatives were explained to the patient. Questions regarding the procedure were encouraged and answered. The patient understands and consents to the procedure. Patient is positioned prone position on the CT scanner in a scout CT of the left femur was acquired.The posterior left thigh was prepped with chlorhexidine in a sterile fashion, and a sterile drape was applied covering the operative field. A sterile gown and sterile gloves were used for the procedure. Once the patient is prepped and draped in the usual sterile fashion the skin and subcutaneous tissues were generously infiltrated with 1% lidocaine for local anesthesia. A spinal needle was used to anesthetize the skin and subcu tissues including the musculature and the periosteum. A small stab incision was made with an 11 blade scalpel, and a 17 gauge guide needle was advanced into the soft tissue lesion of the posterior femur cortex. Once we confirmed position, several 18 gauge core biopsy were achieved. Confirmation of trajectory was confirmed with a coaxial needle through the guide needle.Patient tolerated the procedure well and remained hemodynamically stable throughout. No complications were encountered and no significant blood loss was encountered.

FINDINGS: CT image demonstrates soft tissue lesion at the posterior cortex of the left femur. Coaxial needle system confirms the appropriate trajectory of the biopsy tract into the soft tissue component. No complicating features were identified.

COMPLICATIONS: None

CPT codes -20225, 77012, 99152

You can see the highlighted text in the report which clearly mention the moderate conscious sedation services. So, here we have to take note of the patient age and the time for sedation. Once you calculate the time and age, you will easily reach the CPT code 99152.