Description
This policy addresses reimbursement for anesthesia services that are related to the administration of Moderate (Conscious) Sedation.
Definition
|
Moderate (Conscious) Sedation
|
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
|
Note: Moderate sedation does not include minimal sedation, deep sedation or monitored anesthesia care.
Policy
Blue Cross Blue Shield of North Dakota (BCBSND) will follow the guidelines outlined in the Current Procedural Terminology (CPT) Manual for Moderate (Conscious) Sedation for Preservice Work, Intra-service Work and Post-Service Work. Providers using a sedation scale must ensure the code reported directly reflects the level of sedation provided to the patient in accordance with correct coding.
BCBSND will not reimburse for moderate (conscious) sedation administered by a physician, Qualified Healthcare Practitioner (QHP), Certified Nurse Practitioner Anesthetist (CRNA) or an independent trained observer supervised by the operating surgeon or QHP because it is considered included in the basic service and no additional reimbursement will be allowed.
BCBSND will reimburse for moderate (conscious) sedation provided by a physician, QHP, or CRNA other than the health care professional performing the diagnostic or therapeutic service when the moderate sedation is not supervised by the operating surgeon or QHP.
Gastrointestinal Endoscopic Services
BCBSND allows separate reimbursement for the below codes for anesthesia services when billed by the same physician or QHP performing a gastrointestinal endoscopic service that supports sedation.
Description
|
G0500
|
Moderate sedation services provided by the same physician or QHP performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intra-service time; patient age 5 years of age or older
Note: G0500 is eligible when billed with a qualifying endoscopic service based on CMS guidelines.
|
99153
|
Each additional 15 minutes intra-service time (list separately in addition to code G0500 for primary service)
|
Moderate Sedation by Dentists & Oral Surgeons
BCBSND may allow moderate sedation services rendered by Dentists and Oral Surgeons. BCBSND will separately reimburse for moderate sedation when billed on the same claim as the diagnostic or therapeutic dental service. If a deeper level of sedation is required, the providers must have appropriate documentation in the patient record to support this level of sedation.
Description
|
D7140
|
Extraction, erupted tooth or exposed root (elevation and/or forceps removal)
|
D7210
|
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated
|
D7240
|
Removal of impacted tooth - completely bony
|
D9239
|
Intravenous moderate (conscious) sedation/anesthesia – first 15 minutes
|
D9243
|
Intravenous moderate (conscious) sedation/analgesia – each subsequent 15-minute increment
|
99151
|
Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intra-service time, patient younger than 5 years of age
|
99152
|
Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intra-service time, patient age 5 years or older
|
99153
|
each additional 15 minutes intra-service time (List separately in addition to code for primary service)
|
Limitations & Exclusions
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, payment integrity edits and medical necessity
- Mandated or legislative required criteria will always supersede.
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
Cross References
History
Date
|
Updates
|
11/1/2018
|
Reimbursement Policy Posted to Reimbursement Page. Previous policy listed under HealthCare News Article 396 Moderate (Conscious) Sedation, Issued September 2017.
|
5/14/2020
|
Added documentation requirements.
|
7/16/20
|
Added clarification to the policy indicating the moderate sedation code will be allowed when billed on the same claim as the diagnostic or therapeutic code.
|
8/27/2021
|
Updated to new layout. Added cross references and tables with code descriptions.
|
7/18/2022
|
Reviewed policy and updated link for cross referenced ADA – Guidelines for the Use of Sedation and General Anesthesia by Dentists.
|
7/10/2023
|
Annual policy review completed.
|
