Sedation/analgesia benefits patients by allowing them to tolerate unpleasant procedures by alleviating fear, anxiety, discomfort or pain. In addition, in children and uncooperative adults, sedation and analgesia permits the practitioner to expedite performance of a procedure that requires that the patient not move.

Sedation recognizes four defined levels, but is a continuum that will progress from one level to the next.

• Minimal sedation (anxiolysis) is a drug-induced state wherein the patient follows verbal commands. Cognitive function and coordination may be impaired but there is normal ventilatory and cardiovascular function.
  
  
• Moderate sedation (conscious sedation) is a drug-induced state where consciousness is depressed yet the patient responds purposefully to verbal or light tactile stimuli. The patient maintains a patent airway and has adequate spontaneous ventilation. Cardiovascular function is usually maintained. Moderate sedation does not include monitored anesthesia care (MAC).
  
  
• Deep sedation is a drug-induced state where consciousness is depressed but the patient cannot be easily aroused but will exhibit purposeful responses to repeated noxious or painful stimuli. The ability to independently maintain ventilatory function may be impaired. Assistance may be required to maintain airway patency, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.
  
  
• General anesthesia is a drug-induced loss of consciousness wherein the patient is unarousable, even to painful stimuli. Independent maintenance of ventilatory function is frequently impaired, and assistance is needed to maintain a patent airway. Positive pressure ventilation may be required due to depression of spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may also be impaired.

Safe administration of moderate conscious sedation requires monitoring of multiple physiologic parameters, and these must be documented in the medical record. See Documentation Requirements.

Because moderate conscious sedation may progress to deep sedation or general anesthesia, the availability of emergency resuscitative personnel and equipment is required for patient safety. At a minimum, the equipment must include a source of supplemental oxygen, suction source, airway support and pharmacologic antagonists. In case of an emergency resuscitative effort, ACLS certified personnel must be immediately available.

Sedation/analgesia may be provided by the same physician performing the diagnostic or therapeutic procedure that the sedation supports, or by another physician.

Same physician (codes 99143-99145)
Codes 99143-99145 describe moderate sedation (other than those services described by codes 00100-01999) provided by the same physician 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. These are covered services and separately reimbursed only when the procedures with which moderate sedation is performed are not listed in Appendix G of the CPT codebook.

If the physician performing the procedure also provides a level of anesthesia lower in intensity than moderate or conscious sedation, including but not limited to minimal sedation, simple anxiolysis, local, or topical, the anesthesia service is not separately reimbursed.

When moderate sedation services other than those described by codes 00100-01999 are provided by the same physician performing a diagnostic or therapeutic procedure, listed in Appendix G of the CPT codebook that the sedation supports, the conscious sedation is considered to be an inherent part of providing the procedure and is not separately reimbursed. A provider cannot bill the member for the denied service.

Second Physician (codes 99148-99150)
Codes 99148-99150 describe moderate sedation (other than those services described by codes 00100-01999) provided by a physician other than the health care professional performing the diagnostic or therapeutic service that the sedation supports. In the unusual event when a second physician other than the health care professional performing a diagnostic or therapeutic service listed in Appendix G of the CPT codebook that the sedation supports, provides moderate sedation in a facility setting, the sedation service is covered and separately reimbursed.

The moderate sedation services of the second physician are not covered or reimbursed when performed in a non-facility setting. A provider cannot bill the member for the denied service. Procedures not listed in Appendix G will ordinarily be performed without moderate sedation or under anesthesia described by codes 00100-01999.

Moderate sedation is not medically necessary for procedures performed under local anesthesia, or for peripheral nerve blocks.

Services performed for excessive frequency are not medically necessary. Frequency is considered excessive when services are performed more frequently than generally accepted by peers and the reason for additional services is not justified by documentation.

Documentation Requirements

The patient's medical record must document the medical necessity of services performed for each date of service submitted on a claim, and documentation must be available on request.

1. Patients presenting for moderate conscious sedation will have a sedation-oriented history and will undergo a focused physical examination that includes vital signs, cardiovascular auscultation and airway assessment immediately prior to initiation of sedation.
   
   
2. Periodic contemporaneous monitoring by an independent trained observer who assists in the monitoring of level of consciousness, respiratory function including oxygen saturation, heart rate and blood pressure must be documented. This individual’s sole responsibility should be dedicated to monitoring.
   
   
3. These parameters must be documented before beginning the procedure, following administration of the sedative agents, at five-minute intervals during the procedure, following completion of the procedure, and at discharge from the service area.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CPT Appendix G