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$edation$...time is money

4/21/2015

1 Comment

 
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.

Other Pearls:
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.


Nilesh
1 Comment
aarudhra
5/5/2020 04:43:39

I have just gone through your blog......your information is so valuable. Im Aarudhra from Chennai <a href="https://www.visionaryrcm.com/"><B>ED Coding Services
</B></a>

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  • RESIDENCY
    • About CMC
    • Curriculum
    • Benefits
    • Explore Charlotte
    • Official Site
  • FELLOWSHIP
    • EMS
    • Global EM
    • Pediatric EM
    • Toxicology >
      • Tox Faculty
      • Tox Application
    • (All Others)
  • PEOPLE
    • Program Leadership
    • PGY-3
    • PGY-2
    • PGY-1
    • Alumni
  • STUDENTS/APPLICANTS
    • Medical Students at CMC
    • EM Acting Internship
    • Healthcare Disparities Externship
    • Resident Mentorship
  • #FOAMed
    • EM GuideWire
    • CMC Imaging Mastery
    • Pediatric EM Morsels
    • Blogs, etc. >
      • CMC ECG Masters
      • Core Concepts
      • Cardiology Blog
      • Dr. Patel's Coding Blog
      • Global Health Blog
      • Ortho Blog
      • Pediatric Emergency Medicine
      • Tox Blog
  • Chiefs Corner
    • Top 20
    • Current Chiefs
    • Schedules >
      • Conference/Flashpoint
      • Block Schedule
      • ED Shift Schedule
      • AEC Moonlighting
      • Journal Club/OBP/Audits Schedule
      • Simulation
    • Resources >
      • Fox Reference Library
      • FlashPoint
      • Airway Lecture
      • Student Resources
      • PGY - 1
      • PGY - 2
      • PGY - 3
      • Simulation Reading
      • Resident Wellness
      • Resident Research
      • Resume Builder
    • Individualized Interactive Instruction