99153 FYI Kentucky and Ohio Part B News from CMS and CGS

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March 16, 2017
Clarification of CPT Code 99153
Code Descriptor: Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the 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; each additional 15 minutes intraservice time (list separately in addition to code for primary service)
Billing for moderate sedation services (CPT Codes 99151 or 99152) represents the first 15 minutes of service. All physician work occurs during that first 15 minutes. Usually thereafter, the physician is engaged in performing the procedure, and a nurse will monitor the patient.
The CPT code 99153 represents additional time performed by the nurse (or other personnel). Since the nurse is employed by the facility, incident to billing is not appropriate. Therefore, CPT code 99153 is not payable to the physician since that nurse does not work for him/her, hence the PC/TC indicator 3. There is no physician work involved since he/she is engaged in performing the procedure and the nurse is not employed by the physician. Therefore, the physician cannot bill for the nurse's services. In an office setting where the nurse is employed by the physician, the code will be billable and the practice will get the value of the facility side of the payment (ie. Practice expense and malpractice expense)
CMS has categorized the code with the PC/TC indicator 3 because it essentially behaves like a technical component only code, since there is no physician work
Thank you
Yvette Hofmeister, CPC
Senior Coder OSUP

[The Ohio State University Wexner Medical Center]
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