Good afternoon-

The billing department is stating Medicare does not accept the new code for sedation, each add'l 15 minutes intraservice time (99153) in units, and are requiring the modifier 76 (repeat procedure same provider & DOS). I am having a problem believing this logic since this is not a procedure per se. Please, any insight or confirmation this is correct?



Certified Green Belt, Lean Six Sigma
Assistant Director, Patient Financial Services
Emory Healthcare

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  • There are several payers that don
  • Thank you kindly Todd.


  • edited June 2017
    Below is something one of our providers found...

    Because code 99153 is designated as technical-only, it should not be reimbursed by Medicare when performed in the facility setting (we do not know if other payers will reimburse it separately). While we don't know the CMS logic behind making this code non-reportable in a facility setting, we believe it is because CMS does not want to reimburse more than it did when it was a bundled service.
    We believe that it is CMS's intent that the physician performing the procedure is only entitled to the RVUs that were removed from the previously bundled procedure that he/she is performing. The initial 15-minute code reimburses these RVUs that were removed. CMS removed .25 work RVUs from most of the previously bundled procedure codes; code 99152 is assigned .25 RVUs. The total reimbursement is the same as was previously received.
    The physician performing the procedure can report 99153 in the non-facility setting. It includes payment for the trained observer, the monitoring equipment, and some of the medications administered.
    While the CPT codebook indicates the physician may report 99153 in any setting, CMS doesn't always establish policies consistent with CPT or medical society guidelines.

    Janet Hamm LPN, CPC
    Coding Manager
    Hattiesburg Clinic
    415 South 28th Ave.
    Hattiesburg, MS 39401

  • Thanks Donna, I'm keeping a running file of weird problems with this code. Do you mind saying which MAC this is?
  • edited June 2017

    Janet Hamm LPN, CPC
    Coding Manager
    Hattiesburg Clinic
    415 South 28th Ave.
    Hattiesburg, MS 39401

  • Mine is Cahaba.



  • Noridian isn't paying for it either

    Beth Aldridge, CPC

    Coding Manager

    Northern California Medical Associates, Inc

    Phone: (707) 573-6145

    Fax: (707) 573-6932

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  • Here's what I know so far:

    CCI improperly bundled moderate sedation into about 30 codes. Providers will be able to appeal those denials on or after April 1. https://www.acr.org/Advocacy/eNews/20170106-Issue/20170106-CMS-to-Correct-Errors-to-NCCI-Sedation-Code-Edits

    Novitas recently cleared up an issue that was causing it to deny moderate sedation performed in the non-facility setting. (Palmetto GBA had a similar issue that it has resolved.)

    Noridian's own LCD contains instructions for reporting moderate sedation. https://med.noridianmedicare.com/documents/10534/5321625/Local+Coverage+Determination+for+Monitored+Anesthesia+Care+(MAC)+(L34100) If the denied services weren't performed with codes on the list of improper CCI edits, I'd have to dig a bit.

    For Cahaba GBA, I'll have to keep digging there as well.

    Hope that helps for now. People are welcome to send me issues they're having with these codes: jkyles@decisionhealth.com. Please include the denial codes and the MAC.
  • Thank you SO much.

    Hope you have a fabulous weekend.


  • Yes Under Noridian we have the scenario with G0500. I thought for the first 15 minutes you were to report the G0500 then additional time 99153. We got denials under Noridian for co16 (I called and they said it was their system error didn’t recognize the code) but this was a colonoscopy suite. So we in turn got a denial for the 99153 because they didn't pay any parent code. Now I am seeing denials for Pr49 (denied to patient liability ) during a colonoscopy stating routine services for the conscious sedation and meds!

    Karyn Cardenas-Foray, CPC, CPMA ,CHCA, CEMC,CIMC,CSEMC
    Government Reimbursement Analyst-Sharp Health Care
    PFS-CCD 3rd Floor

  • If you look at the CMS fee schedule they did not load any professional RVU units to the add-on code. It reflects a technical RVU only for 99153, and no professional.

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