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Moderate sedation services refer to the administration of sedative agents to a patient to facilitate a diagnostic or therapeutic procedure while ensuring the patient remains in a state of controlled consciousness. This service is specifically provided by a physician or another qualified healthcare professional who is not the individual performing the actual procedure that necessitates sedation. The process begins with a thorough patient assessment to evaluate the patient's medical history and current health status. An intravenous (IV) line is then established to allow for the administration of fluids and sedative medications as required. The sedative agent is carefully administered, and the patient is continuously monitored throughout the procedure. This monitoring includes assessing the patient's level of consciousness and vital physiological parameters such as oxygen saturation, heart rate, and blood pressure to ensure safety and effectiveness. 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, at which point the patient can be safely handed over to nursing staff for ongoing care. It is important to note that different codes are used for patients based on their age: CPT® Code 99155 is designated for patients younger than 5 years old, while CPT® Code 99156 is applicable for patients aged 5 years or older, and CPT® Code 99157 is used for each additional 15 minutes of intraservice time required for sedation.
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The indications for moderate sedation services are primarily associated with the need to facilitate diagnostic or therapeutic procedures that may cause discomfort or anxiety to the patient. These procedures may include, but are not limited to, endoscopic examinations, certain dental procedures, and minor surgical interventions. The use of moderate sedation is particularly indicated for patients who may require assistance in managing pain or anxiety during these procedures, ensuring that they remain calm and comfortable while still being able to respond to verbal commands.
The procedure for administering moderate sedation involves several critical steps to ensure patient safety and comfort. Initially, a comprehensive patient assessment is conducted to evaluate the patient's medical history, current medications, and any potential allergies. This assessment helps determine the appropriateness of moderate sedation for the individual patient. Following the assessment, an intravenous (IV) line is established, allowing for the administration of fluids and sedative agents. The healthcare professional then carefully administers the sedative agent, monitoring the patient's response closely. Throughout the procedure, the patient's level of consciousness and vital signs, including oxygen saturation, heart rate, and blood pressure, are continuously monitored to ensure that the patient remains stable and safe. The healthcare provider must be prepared to intervene if any adverse reactions occur. Once the procedure is completed, the healthcare professional continues to monitor the patient until they have adequately recovered from the sedation effects, ensuring that the patient is stable before transferring them to nursing staff for further care.
Post-procedure care following moderate sedation is crucial for ensuring patient safety and recovery. After the completion of the procedure, the healthcare professional remains with the patient to monitor their vital signs and level of consciousness until they have sufficiently recovered from the effects of the sedative. This monitoring period is essential to identify any potential complications or adverse reactions that may arise as the sedation wears off. Once the patient is stable and alert, they can be safely transferred to nursing staff for continued care. It is important to provide the patient with post-sedation instructions, including information about potential side effects, activity restrictions, and when to seek further medical attention. Patients should also be advised not to drive or operate heavy machinery for a specified period following sedation, as their cognitive and motor skills may still be impaired.
| Short Descr | MOD SED OTH PHYS/QHP 5/>YRS | Medium Descr | MOD SED OTHER PHYS/QHP INITIAL 15 MINS 5/> YRS | Long Descr | Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient age 5 years or older | Status Code | Active Code | Global Days | XXX - Global Concept Does Not Apply | PC/TC Indicator (26, TC) | 9 - Not Applicable | Multiple Procedures (51) | 9 - Concept does not apply. | Bilateral Surgery (50) | 9 - Concept does not apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 9 - Concept does not apply. | Co-Surgeons (62) | 9 - Concept does not apply. | Team Surgery (66) | 9 - Concept does not apply. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Items and Services Packaged into APC Rates | Berenson-Eggers TOS (BETOS) | Y1 - Other - Medicare fee schedule | MUE | 1 |
This is a primary code that can be used with these additional add-on codes.
| 99157 | CPT Add On MPFS Status: Active Code APC N Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes intraservice time (List separately in addition to code for primary service) |
| GC | This service has been performed in part by a resident under the direction of a teaching physician | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | XP | Separate practitioner, a service that is distinct because it was performed by a different practitioner | X4 | Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period | 25 | Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service: it may be necessary to indicate that on the day a procedure or service identified by a cpt code was performed, the patient's condition required a significant, separately identifiable e/m service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. a significant, separately identifiable e/m service is defined or substantiated by documentation that satisfies the relevant criteria for the respective e/m service to be reported (see evaluation and management services guidelines for instructions on determining level of e/m service). the e/m service may be prompted by the symptom or condition for which the procedure and/or service was provided. as such, different diagnoses are not required for reporting of the e/m services on the same date. this circumstance may be reported by adding modifier 25 to the appropriate level of e/m service. note: this modifier is not used to report an e/m service that resulted in a decision to perform surgery. see modifier 57 for significant, separately identifiable non-e/m services, see modifier 59. | 47 | Anesthesia by surgeon: regional or general anesthesia provided by the surgeon may be reported by adding modifier 47 to the basic service. (this does not include local anesthesia.) note: modifier 47 would not be used as a modifier for the anesthesia procedures. | 53 | Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 77 | Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | AA | Anesthesia services performed personally by anesthesiologist | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | CR | Catastrophe/disaster related | FS | Split (or shared) evaluation and management visit | GA | Waiver of liability statement issued as required by payer policy, individual case | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | GW | Service not related to the hospice patient's terminal condition | GZ | Item or service expected to be denied as not reasonable and necessary | LT | Left side (used to identify procedures performed on the left side of the body) | MG | The order for this service does not have applicable appropriate use criteria in the qualified clinical decision support mechanism consulted by the ordering professional | P2 | A patient with mild systemic disease | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | RT | Right side (used to identify procedures performed on the right side of the body) | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2017-01-01 | Added | Added |
| 1989-12-31 | Deleted | Code deleted. |
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