Moderate sedation time

New codes 99152 99153 The CPT book explains that the time will be based on intraservice only. The codes read 15 minutes. They do not state greater than, equal to, no less than etc.
However, when you look at the chart in the CPT book it tells a different story.
Less than 10 min, do not bill.
10-22 which is 15 min with 5-7 minutes leftover, only bill first 15.
23-37 which is (23) 15 min with 8 min left over or (37) 30 min with 7 left over – you get two codes but the remaining 7 min of 37 is not billable.
So it appears that initial 15 is 10 or more min to be billable and each additional is a minimum of 8 additional min to be billable. Any left over 7 and under is not billable.
So where does this come from? It is not in the CPT descriptions or in the code guidelines.

Thank you
Yvette Hofmeister, CPC
Senior Coder -OSUP
614-685-2915

Comments

  • edited May 2017
    The table(s) in the CPT manual ARE CPT guidelines.


  • The advice in the PRIVATELY owned AMA are the opinions of the AMA and only of the AMA and should not be taken as enforceable and lawful rules by any physician or insurance carrier. The CMS, HHS, Medicare, Tricare and Medicaid may have rules that are similar to the AMA - but most of the time - they are different and separate. There are too many instances where using the CPT rules to apply to Medicare or using the Medicare rules to apply to commercial carriers will cause problems for the provider. Keep them separate is my opinion.


    Don
    Don Self & Associates, Inc

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  • CPT Guidelines for time based services state that "A unit of time is attained when the mid-point is passed." So it would seem that the minimum requirement for a 15 minute code would be 8 minutes. However, CPT Guidelines also state that these standards shall apply "unless there are code or code-range–specific instructions in guidelines, parenthetical instructions, or code descriptors to the contrary."

    In this case there are "guidelines, parenthetical instructions" to the contrary. The Moderate sedation guidelines state that less than 10 minutes is not separately reportable. Those instructions override the standard CPT time instructions.

    To qualify for the additional 15 minute code you still need to pass the half way point of the extra 15 minutes. So 8 minutes past 15 minutes is 23 minutes.

    The base code covers 10 mins to 22 mins as indicated in the moderate sedation guidelines.

    Hope this helps.

    TT

    Todd Thomas, CPC, CCS-P ERcoder, Inc
    President 941 NW 164th, Suite 1
    todd@ercoder.com Edmond, OK 73013
    (405) 749-2633 www.ERcoder.com

  • The time rule has always been that it must be at least half of the 15. But you have to perform at least half of 15, 30, 45 etc.

    Remember if doing endoscopy for Medicare there is a separate G code with different timing.

    Ruby Woodward
    Sent from my iPhone

    > On Dec 15, 2016, at 2:13 PM, Hofmeister, Yvette wrote:
    >
    > New codes 99152 99153 The CPT book explains that the time will be based on intraservice only. The codes read 15 minutes. They do not state greater than, equal to, no less than etc.
    > However, when you look at the chart in the CPT book it tells a different story.
    > Less than 10 min, do not bill.
    > 10-22 which is 15 min with 5-7 minutes leftover, only bill first 15.
    > 23-37 which is (23) 15 min with 8 min left over or (37) 30 min with 7 left over – you get two codes but the remaining 7 min of 37 is not billable.
    > So it appears that initial 15 is 10 or more min to be billable and each additional is a minimum of 8 additional min to be billable. Any left over 7 and under is not billable.
    > So where does this come from? It is not in the CPT descriptions or in the code guidelines.
    >
    > Thank you
    > Yvette Hofmeister, CPC
    > Senior Coder -OSUP
    > 614-685-2915
    >
    >
    >
  • As Todd mentioned, CPT states that the mid-point must normally be "passed," i.e., more-than-half the code's time to bill time-based codes. As he pointed out, though, CPT says this normal time-based billing rule can be superceded by specific wording in CPT for the codes in question. For example, for Critical Care codes, the first-hour code can be billed when you've exactly reached the mid-way point (30 minutes), as opposed to the 31-minute threshold that would have been in place under normal time-based billing rules that say the mind-point must be passed. This exception is good for us.

    For the new conscious sedation codes, the chart makes it clear that you can NOT bill the initial 15-minute code at 8 minutes as we would normally expect, but instead at least 10 minutes must have been provided. This exception does not favor us, but it is the rule.

    Seth Canterbury, CPC, CPC-I
    Clinical Data Quality Education Department
    University of Florida Jacksonville Physicians, Inc.
    653 West Eighth Street
    Tower I, Suite 606
    Jacksonville, FL 32209

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