Procedural Sedation Documentation Pearls
Our ER notes need to clearly document the sedation time. Referring to RN notes is not adequete as it is difficult for coders to follow the flow sheet accurately.
For a Procedural Sedation to be billable, "intraservice" sedation time documented needs to be at least 16 minutes.
"Moderate sedation is a time based code. Because the Moderate Sedation codes indicate a unit of time of 30 minutes, the ED chart must indicate 16 minutes or more of intraservice time to report Moderate Sedation. If the time threshold has not been met, then the code is not reportable." - Oct 2011 CPT Assistant
Units of time billable for procedural sedation are:
Per CPT, a unit of time is attained when the midpoint has been passed.
Initial 30 minutes (must document at least 16 minutes to get reimbursed)
Each addition 15 minutes can be billed.
Must document at least 37.5 minutes for up to 45 minutes [30 min unit + one 15 min unit];
Must document at least 52.5 minutes for up to 60 minutes [30 min unit + two 15 min units], etc...
Intraservice time is defined as:
Starts with the administration of the sedation agent(s)
Requires continuous face-to-face attendance
Ends at the conclusion of personal contact by the physician providing the sedation.
Documentation should include the name of the procedure, medication names, dosages and routes of administration, who administered the medication(s) (physician or observer), notations of ongoing assessments and vital signs monitoring during moderate sedation. Using the Procedural Sedation sentence in PowerNote includes all of these elements.
Our billing department does not have access to the MUSE application. A statement such as "Please see MUSE for complete EKG interpretation" doesn't always get billed. Reasons are multi-factorial.
For EKG billing, you must document 3 of 6 of the following elements:
1. Rhythm or rate
5. Notation of comparison to prior EKG
6. Summary of clinical condition
I recommend making it easy on the coders. Try not to bury the EKG interpretation in a long paragraph. Use the EKG click box or separate it in your dictation.
You can bill for more than 1 EKG. Clearly document each EKG interpretation. From a medical legal viewpoint, it's always in your benefit to time your EKG reads.
For Past Medical/Surgical, Social, Family History:
"Negative," "noncontributory," "not significant," "unknown," or "reviewed in chart" are not considered sufficient to support these history components.
** For "unknown" you must clearly indicate a high acuity caveat or document if the patient is adopted.
*** Our coders do not reference nursing notes for "reviewed in chart." These must be imported into your power note for the coder to see it.
**** It is ok to say "No past medical history"
Disclaimer: Information contained in this blog is the opinion of the author and does not necessarily reflect the official opinion of Carolinas HealthCare System. Application of material contained in this blog is at the discretion of the practitioner to verify for accuracy.