Learn the A-B-ZZZs of Reporting Moderate

Sedation
By Susan Dooley

Coders and providers often have misconceptions about coding for moderate sedation, also known as
conscious or twilight sedation. First of all, lets define moderate sedation. From an awareness standpoint
for the patient, moderate sedation is a depressed level of consciousness. Patients who have moderate
sedation along with analgesic agents should be relatively pain free during the procedure, as well as calm,
tranquil, and unable to remember the procedure. Whats the advantage of moderate sedation over
other types of anesthesia, such as general? With moderate anesthesia, patients can still maintain a
The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713, Eenterprise Contact: Sam Nair, Direct: 704 303 8150,
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patent airway that is, their tracheas remain open as well as respond appropriately to both physical
stimulation and verbal commands. Lets bust some myths about anesthesia coding and moderate
sedation.

Myth 1: Sedation is Sedation is Sedation

Actually, its not. According to the American Society of Anesthesiologists (ASA), sedation comes in four
levels: Minimal, moderate, deep, and general. Weve already talked about moderate sedation, which is
often used for procedures such as esophagogastroduodenoscopy and colonoscopy. Minimal sedation is
also sometimes called anxiolysis, which means anxiety reducing; this is a drug-induced relief of
apprehension with only minimal effect on consciousness and sensation.
With deep sedation, consciousness is depressed to the point that the patient cannot be aroused;
however, he or she can respond to painful or repeated stimuli. Unlike with minimal and moderate
sedation, with deep sedation patients may not be able to maintain their own airways or breathe on their
own. General anesthesia is the fourth type of sedation: This is a state of unconsciousness, one where
the autonomic nervous system cannot respond to surgical or procedural stimuli.

Myth 2: Only Anesthesiologists Perform Moderate Sedation

No again in fact, CPTs section of moderate sedation codes was reworked a few years back to allow
reporting of cases where non-anesthesiologist physicians sedate patients. (Specifically, these are
moderate sedation codes 99143-+99145, for sedation performed by the same provider who performs
the procedure.)
If your physician administers moderate anesthesia before she performs an injection or nerve block for
therapeutic services, you can report a moderate anesthesia code along with the procedure code. To see
services that cannot be reported with a separate moderate sedation code, check CPT codes for a bulls
eye symbol. These procedures are also listed in Appendix G of the CPT Manual.

Myth 3: Providers Can Monitor Sedation While Doing the Procedure

Nope! Moderate anesthesia requires an independent trained observer to assist in monitoring the
patients status while the procedure is ongoing to ensure patient safety. This means that even if the
provider is a trained anesthesiologist acting as surgeon to administer a nerve block, for example, that
anesthesiologist must have a trained independent observer, such as a registered nurse with Basic Life
Support (BLS) or Advanced Cardiac Life Support (ACLS) certification. That observer must be fully
dedicated to monitoring the patient, administering drugs, and recording what happens during the
sedation period. The moderate sedation codes specifically state this in their descriptors.

What About You?

Do you have any tips to share about anesthesiology coding? Let us know.
The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713, Eenterprise Contact: Sam Nair, Direct: 704 303 8150,
shyamn@codinginstitute.com

Keep Up With Changes in Coding With Anesthesia Coding Alert!

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Contact Us:
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Email: shyamn@codinginstitute.com
Direct: 704 303 8150

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The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713

The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713, Eenterprise Contact: Sam Nair, Direct: 704 303 8150,
shyamn@codinginstitute.com