This policy addresses coverage and reimbursement for anesthesia services that are related to the administration of Moderate (Conscious) 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, deep sedation or monitored anesthesia care.
Reimbursement is not available for moderate (conscious) sedation administered by a physician or Qualified Healthcare Practitioner (QHP), Certified Nurse Practitioner Anesthetist (CRNA) or an independent trained observer supervised by the operating surgeon because it is considered included in the basic service and no additional reimbursement will be allowed.
Reimbursement will be allowed for moderate (conscious) sedation provided by a physician or QHP other than the health care professional performing the diagnostic or therapeutic service when the moderate sedation code is billed on the same claim as the diagnostic or therapeutic service.
Blue Cross Blue Shield of North Dakota (BCBSND) will follow the guidelines outlined in the 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.
Gastrointestinal Endoscopic Services
BCBSND made the following change to billing and coding of anesthesia services when billed by the same physician or other QHP performing a gastrointestinal endoscopic service that sedation supports. This change was made because of the rules implemented by the Center for Medicare & Medicaid Services (CMS) on January 1, 2017. Effective July 1, 2017, the following guidelines apply for eligible services:
HCPC Level II® G0500 - Moderate sedation services provided by the same physician or other qualified health care professional 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
CPT® 99153 - Each additional 15 minutes intra-service time (list separately in addition to code G0500 for primary service)
Qualifying gastrointestinal endoscopic services include those CPT®/HCPCS codes identified and published by CMS as eligible to be billed with G0500.
Medical Services Rendered by Dentists and Oral Surgeons
BCBSND may allow moderate sedation services rendered by dentists and oral surgeons for appropriate D Codes, such as D7140, D7210, and D7240. When billing for moderate sedation, dentists and oral surgeons can use CPT Codes 99151 or 99152 and 99153; or D9239 and D9243. The moderate sedation code will be allowed for separate reimbursement when billed on the same claim as the diagnostic or therapeutic dental service.
If a deeper level of sedation is required, D9222 and D9223 may be used. If these codes are billed, providers must have appropriate documentation in the patient record to support this level of sedation.
1. CMS Moderate Sedation Work Values Table
2. CPT ®
3. HCPC Level II
Limitations and 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, 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.