REIMBURSEMENT POLICY

MODERATE SEDATION POLICY

Policy Number: ANESTHESIA 002.24 T0
Effective Date: April 1, 2016

Table of Contents Page Related Policy:

Supply Policy
APPLICABLE LINES OF BUSINESS/PRODUCTS... 1
APPLICATION........................................... 1
OVERVIEW.................................................................. 1
REIMBURSEMENT GUIDELINES............................... 2
DEFINITIONS.............................................................. 4
QUESTIONS AND ANSWERS.................................... 4
ATTACHMENTS.......................................................... 5
RESOURCES/REFERENCES..................................... 5
POLICY HISTORY/REVISION INFORMATION........... 5

The services described in Oxford policies are subject to the terms, conditions and limitations of the
Member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare
Advantage enrollees. Oxford reserves the right, in its sole discretion, to modify policies as
necessary without prior written notice unless otherwise required by Oxford's administrative
procedures or applicable state law. The term Oxford includes Oxford Health Plans, LLC and all of
its subsidiaries as appropriate for these policies.

Certain policies may not be applicable to Self-Funded Members and certain insured products.
Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage
is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If
there is a difference between any policy and the Members plan of benefits or Certificate of
Coverage, the plan of benefits or Certificate of Coverage will govern.

APPLICABLE LINES OF BUSINESS/PRODUCTS

This policy applies to Oxford Commercial plan membership.

Note: While precertification is not required for moderate sedation, it may be required for the
therapeutic and/or diagnostic procedures for which sedation is being provided.

APPLICATION

This reimbursement policy applies to services reported using the UB-04 claim form, the 1500
Health Insurance Claim Form (a/k/a CMS-1500), or their electronic equivalents or their successor
forms. This policy applies to all network and non-network providers, including hospitals,
ambulatory surgical centers, physicians and other qualified health care professionals including,
but not limited to, non-network authorized and percent of charge contract physicians and other
qualified health care professionals.

OVERVIEW

Current Procedural Terminology (CPT) defines Moderate (conscious) Sedation as a drug

induced depression of consciousness during which patients respond purposefully to verbal

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commands, either alone or accompanied by light tactile stimulation. In addition, no interventions
are required to maintain a patent airway and spontaneous ventilation is adequate. Cardiovascular
function is usually maintained. Moderate Sedation does not include Minimal Sedation (anxiolysis),
deep sedation, or monitored anesthesia care (CPT codes 00100-01999).

Moderate Sedation services reported by the same physician, hospital, ambulatory surgical center,
or other qualified health care professional reporting the diagnostic or therapeutic procedure, are
separately reimbursable services when submitted under CPT codes 99143-99145 except when
reported with the procedures noted below.

In a facility setting, Moderate Sedation services performed by a second physician, hospital,

ambulatory surgical center or other qualified health care professional are separately reimbursable
services when submitted under CPT codes 99148-99150. In a non-facility setting, CPT codes
99148-99150 will not be reimbursed when the same physician, hospital, ambulatory surgical
center or other qualified health care professional also reports a code listed in Appendix G of the
CPT codebook.

Note: Based on their intended use, Moderate Sedation codes 99148-99150 would not be
reported with diagnostic or therapeutic procedures.

Oxford's reimbursement policy for Moderate Sedation services is based on methodologies used
and recognized by the Centers for Medicare and Medicaid Services (CMS) National Correct
Coding Initiative (NCCI) edits and Policy Manual, and CPT codebook guidelines.

For purposes of this policy, same physician, hospital, ambulatory surgical center or other qualified
health care professional is defined as the same physician, hospital, ambulatory surgical center or
other qualified health care professional rendering health care services reporting the same
Federal Tax Identification number.

REIMBURSEMENT GUIDELINES

Attending Physician (99143-99145)

Oxford will allow separate reimbursement for Moderate Sedation services reported as CPT codes
99143-99145 when provided by the Same Physician, hospital, ambulatory surgical center, or
other qualified health care professional reporting the diagnostic or therapeutic procedure except
when reported with:

1. Procedures listed in Appendix G of the CPT book

2. Anesthesia procedures (CPT codes 00100-01999)
3. CPT and HCPCS codes that are part of CMS NCCI edits

These procedures include Moderate Sedation as an inherent part of providing the service. Refer
to the list below for a comprehensive listing of the non-anesthesia procedures that include
Moderate Sedation and for which CPT codes 99143-99145 will not be considered separately.

Procedures that include Moderate Sedation codes (99143-99145)

Note: Procedure codes that are listed in Appendix G of the CPT book that are also identified on
the National Physicians Fee Schedule (NPFS) as Status B are addressed in the B Bundle Codes
Policy.

Second Physician (99148-99150)

Moderate Sedation services performed by a second physician, hospital, ambulatory surgical
center, or other qualified health care professional (who is not performing the diagnostic or
therapeutic procedure that the sedation supports), should be reported as CPT codes 99148-
99150. Reimbursement of CPT codes 99148-99150 based on the place of service is as follows:

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Non-facility setting
According to the AMA When moderate sedation is performed in the non-facility setting, the
efforts of the second physician are not reported with the codes in Appendix G because moderate
sedation is included in these codes. Therefore, it would not be appropriate to separately report for
moderate sedation. Based on AMA guidelines, Oxford will reimburse CPT codes 99148-99150 in
a non-facility setting except when a procedure code listed in Appendix G of the CPT codebook is
also reported on the same date of service by the same physician or other qualified health care
professional.

Facility setting
Moderate Sedation services reported as CPT codes 99148-99150 that are performed by a
second physician, hospital, ambulatory surgical center, or other qualified health care professional
in a facility place of service (see listing below) are eligible for reimbursement.

For purposes of this policy a facility place of service would include any of the following locations:

19 Off Campus-Outpatient Hospital

21 Inpatient Hospital
22 On Campus-Outpatient Hospital
23 Emergency Room-Hospital
24 Ambulatory Surgical Center
26 Military Treatment Facility
31 Skilled Nursing Facility
34 Hospice
41 Ambulance - Land
42 Ambulance - Air or Water
51 Inpatient Psychiatric Facility
52 Psychiatric Facility - Partial Hospitalization
53 Community Mental Health Center
56 Psychiatric Residential Treatment Center
61 Comprehensive Inpatient Rehabilitation Facility

For additional information, refer to the Questions and Answers section, Q&A #1 and #3.

Drug Reimbursement
The cost of the drug used in Moderate Sedation, if supplied by the physician in a location other
than inpatient/outpatient hospital, emergency room or ambulatory surgical center, is reimbursable
at the appropriate fee schedule or contracted rate. For additional information on drugs supplies in
an inpatient/outpatient hospital, emergency room or ambulatory surgical center, refer to the
Supply Policy.

The Current Procedural Terminology (CPT ) codes and Healthcare Common Procedure Coding
System (HCPCS) codes listed in this policy are for reference purposes only. Listing of a service
code in this policy does not imply that the service described by this code is a covered or non-
covered health service. Coverage is determined by the member specific benefit document and
applicable laws that may require coverage for a specific service. The inclusion of a code does not
imply any right to reimbursement or guarantee claims payment. Other policies and coverage
determination guidelines may apply. This list of codes may not be all inclusive.

CPT Code Description
Moderate sedation services (other than those services described by codes
00100-01999) provided by the same physician performing the diagnostic or
therapeutic service that the sedation supports, requiring the presence of an
99143
independent trained observer to assist in the monitoring of the patients level of
consciousness and physiological status; under 5 years of age, first 30 minutes
intra-service time

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CPT Code Description
Moderate sedation services (other than those services described by codes
00100-01999) provided by the same physician performing the diagnostic or
therapeutic service that the sedation supports, requiring the presence of an
99144
independent trained observer to assist in the monitoring of the patients level of
consciousness and physiological status; age 5 years or older, first 30 minutes
intra-service time
Moderate sedation services (other than those services described by codes
00100-01999) provided by the same physician performing the diagnostic or
therapeutic service that the sedation supports, requiring the presence of an
99145
independent trained observer to assist in the monitoring of the patients level of
consciousness and physiological status; each additional 15 minutes intra-service
time (List separately in addition to code for primary service)
Moderate sedation services (other than those services described by codes
00100-01999), provided by a physician other than the health care professional
99148
performing the diagnostic or therapeutic service that the sedation supports; under
5 years of age, first 30 minutes intra-service time
Moderate sedation services (other than those services described by codes
00100-01999), provided by a physician other than the health care professional
99149
performing the diagnostic or therapeutic service that the sedation supports; age 5
years or older, first 30 minutes intra-service time
Moderate sedation services (other than those services described by codes
00100-01999), provided by a physician other than the health care professional
99150 performing the diagnostic or therapeutic service that the sedation supports; each
additional 15 minutes intra-service time (List separately in addition to code for
primary service)
CPT is a registered trademark of the American Medical Association.

DEFINITIONS

Minimal Sedation: Minimal Sedation (anxiolysis) is a drug-induced state during which patients
respond normally to verbal commands. Although cognitive function and coordination may be
impaired, ventilatory and cardiovascular functions are unaffected.

Moderate Sedation: Moderate (conscious) Sedation is a drug induced depression of

consciousness during which patients respond purposefully to verbal commands, either alone or
accompanied by light tactile stimulation. No interventions are required to maintain a patent
airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.
Moderate Sedation does not include Minimal Sedation (anxiolysis), deep sedation, or monitored
anesthesia care (CPT codes 00100-01999).

Same Physician, Hospital, Ambulatory Surgical Center, or Other Qualified Health Care
Professional: The same physician, hospital, ambulatory surgical center or other qualified health
care professional rendering health care services reporting the same Federal Tax Identification
number.

QUESTIONS AND ANSWERS

Q1: A second physician has rendered Moderate Sedation in a non-facility setting for a
procedure listed in Appendix G of the CPT codebook reported by the attending physician. Will
the second physicians services be separately reimbursed?
A1: No. When Moderate Sedation is performed in the non-facility setting, the efforts of the
second physician are not reported with the codes in Appendix G because Moderate Sedation
is included in these codes. In a non-facility setting the second physician is considered the
trained observer, and should be reimbursed by the attending physician.

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 Q2: In the policy overview it states: Moderate Sedation does not include Minimal Sedation
(anxiolysis). What are some examples of Minimal Sedation?
A2: According to the report titled Practice Guidelines for Sedation and Analgesia by Non-
Anesthesiologists (obtained from the ASA website), "Examples of minimal sedation include
peripheral nerve blocks, local or topical anesthesia, and either (1) less than 50% nitrous
oxide (N2O) in oxygen with no other sedative or analgesic medications by any route, or (2) a
single, oral sedative or analgesic medication administered in doses appropriate for the
unsupervised treatment of insomnia, anxiety, or pain."

Q3: Why would it be appropriate to report CPT codes 99148-99150 for an Appendix G
procedure when performed in a facility place of service?
A3: According to the AMA, the provision of sedation by a second provider would not be the
normal course of action and that implies a different intensity of work for these services than
would be the case when it is inherent to the procedure. This work would properly be
performed in a facility, not a non-facility, place of service.

ATTACHMENTS

Procedures that include Moderate Sedation Codes 99143-99145

This comprehensive list identifies the codes contained in Appendix G of the CPT book and
codes that are part of CMS NCCI edits for procedures that include Moderate Sedation
services. The codes on this list do not allow separate reimbursement for Moderate Sedation
codes 99143-99145.

RESOURCES/REFERENCES

The foregoing Oxford policy has been adapted from an existing UnitedHealthcare national policy
that was researched, developed and approved by UnitedHealthcare Payment Policy Oversight
Committee. [2015R0035A]

1. Centers for Medicare and Medicaid Services, CMS Manual System and other CMS
publications and services.

2. Centers for Medicare and Medicaid Services, National Correct Coding Initiative (NCCI)
publications.

3. American Medical Association, Current Procedural Terminology (CPT) and associated

publications and services.

4. Publications and services of the American Society of Anesthesiologists (ASA).

POLICY HISTORY/REVISION INFORMATION

Date Action/Description
Revised list of Procedures that include Moderate Sedation Codes
99143-99145 (attachment file detailing procedures that do not
allow separate reimbursement for moderate sedation CPT codes
99143-99145):
o Added 0394T, 0395T, 0424T, 0425T, 0426T, 0427T, 0428T,
04/01/2016
0429T, 0430T, 0431T, 0432T, 0433T, 0434T, 0435T, 0436T,
43210, 45399, 61645, 77767, 77768, 77770, 77771 and
77772
o Removed 0387T, 0388T, 37217, 93355 and G0448
Archived previous policy version ANESTHESIA 002.23 T0

Moderate Sedation Policy: Reimbursement Policy (Effective 04/01/2016) 5

1996-2016, Oxford Health Plans, LLC