Limitations Based on the CPT Definitions
99143–99145
An independent trained observer whose sole duty is to monitor the patient’s level of consciousness and physiological status must be present throughout the diagnostic or therapeutic service. The anesthesia note must identify this person and his credentials (e.g., RN, NPP, PA).
“Intra-service time starts with the administration of the sedation agent(s), requires continuous face-to-face attendance, and ends at the conclusion of personal contact by the physician providing the sedation.” (Per CPT)
Do not report 99143–99145 with codes listed in Appendix G of the CPT book. (These codes include payment for moderate sedation.)
99148–99150
May be used only in a facility setting: hospital, outpatient hospital, Ambulatory Surgical Center (ASC), Skilled Nursing Facility (SNF).
Do not report 99148–99150 with codes listed in Appendix G if performed in a non-facility setting.
“Intra-service time starts with the administration of the sedation agent(s), requires continuous face-to-face attendance, and ends at the conclusion of personal contact by the physician providing the sedation.” (Per CPT)
The sedation service must be medically necessary for the management of the patient. Preliminary data analysis of claims submitted for these services indicates that 99144–99145 are being billed with routine injection services and other minor procedures for which moderate sedation may not be “reasonable.” Title XVIII of the Social Security Act, Section 1862(a)(1)(A), states “… No payment may be made under Part A or Part B for any expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”
Report only the time of face-to-face physician contact, starting with the time when the physician starts the anesthesia to the time the physician breaks face-to-face contact. The reported time stops when the physician breaks face-to-face contact, even if the trained observer stays for a longer period of time to monitor recovery. The additional time the trained observer stays to monitor recovery after the physician leaves the patient’s bedside is not a service separately billable to Medicare. The Medicare “incident to” provisions do not apply to this service since the service is defined in terms of face-to-face physician time.
These codes may not be used to report a level of anesthesia lower in intensity than moderate or conscious sedation such as local or topical anesthesia or minimal sedation.
For this service, Medicare defines a “physician” as an MD, DO or other physicians and non-physician practitioners licensed by the state to perform conscious sedation in addition to the diagnostic or therapeutic service for which sedation is required.
When billing 99143–99145, the physician performing the diagnostic or therapeutic service must also bill for the anesthesia service on the same claim and must be licensed to perform both the diagnostic or therapeutic service and the anesthesia service.
Documentation must include a separate anesthesia note with a patient assessment, the method and route of administration of conscious sedation, start and stop times, baseline vital signs, vital signs every 5 to 15 minutes (depending on patient status), identity of trained observer (for codes 99143–99145), method of monitoring heart rate, oxygen saturation (if any) and recovery time.
The provider must make the anesthesia note and the justification from the medical record of the medical necessity of the service available upon request.
