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Moderate sedation services, as defined by CPT® Code 99145, are specialized medical services provided by the same physician or qualified healthcare professional who is conducting a diagnostic or therapeutic procedure that necessitates sedation. This service is characterized by the requirement of an independent trained observer who assists in monitoring the patient's level of consciousness and physiological status throughout the procedure. The process begins with a thorough patient assessment, which is crucial for determining the appropriate sedation level and ensuring patient safety. An intravenous line is typically inserted to facilitate the administration of fluids and sedative agents as needed. The administration of the sedative agent is carefully managed to maintain the patient under moderate sedation, allowing for a balance between sedation and responsiveness. During the procedure, vital signs such as oxygen saturation, heart rate, and blood pressure are continuously monitored to ensure the patient's safety and well-being. After the procedure is completed, the physician or qualified healthcare professional remains vigilant in monitoring the patient until they have sufficiently recovered from the effects of sedation. Only then can the patient be safely handed over to nursing staff for ongoing care. It is important to note that for patients younger than five years old, CPT® Code 99143 is used for the first 30 minutes of moderate sedation, while CPT® Code 99144 is applicable for patients aged five years or older for the same duration. CPT® Code 99145 is specifically designated for billing each additional 15 minutes of intra-service time for patients of any age, ensuring that the complexity and duration of sedation services are accurately captured in the medical coding process.
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The indications for moderate sedation services provided under CPT® Code 99145 include situations where a patient requires sedation during a diagnostic or therapeutic procedure. These procedures may involve various medical interventions that necessitate the patient to be in a state of moderate sedation to ensure comfort and cooperation. The following conditions may warrant the use of moderate sedation:
The procedure for administering moderate sedation services under CPT® Code 99145 involves several critical steps to ensure patient safety and comfort. Each step is essential for the effective management of sedation during the diagnostic or therapeutic service.
Post-procedure care following moderate sedation services involves careful monitoring of the patient as they recover from sedation. The healthcare professional must ensure that the patient is alert and stable before they can be safely handed over to nursing staff. This includes checking vital signs and assessing the patient's responsiveness. The patient may experience residual effects of sedation, such as drowsiness or confusion, which should be taken into account during the recovery phase. It is also important to provide the patient and their caregivers with instructions regarding post-sedation care, including any restrictions on activities, dietary recommendations, and signs of potential complications that should prompt immediate medical attention. The overall goal is to ensure a safe and smooth transition from the sedation state back to normal functioning.
| Short Descr | MOD SEDAT PHYS/QHP EA 15 MIN | Medium Descr | MODERATE SEDATJ SAME PHYS/QHP EACH ADDL 15 MIN | Long Descr | Moderate sedation services (other than those services described by codes 00100-01999) provided by the same physician or other qualified health care professional performing the diagnostic or therapeuti | Status Code | Carriers Price the Code | Global Days | ZZZ - Code Related to Another Service | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 0 - No payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 9 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Items and Services Packaged into APC Rates | Type of Service (TOS) | 7 - Anesthesia | Berenson-Eggers TOS (BETOS) | P6C - Minor procedures - other (Medicare fee schedule) | MUE | Not applicable/unspecified. | CCS Clinical Classification | 232 - Anesthesia |