Documentation Tips

Documentation Tips: PROCEDURAL / MODERATE SEDATION

Documentation Tips: Procedural / Moderation Sedation

Procedural sedation is a drug induced depression of consciousness. In moderate sedation the patient maintains the ability to respond purposefully to verbal direction either alone or accompanied by light tactile stimulation. Interventions are not required to maintain the patient’s airway. Short term deep sedation is the most common sedation event in the ED usually involving complete loss of consciousness. It is generally accepted that in the emergency care setting these services are properly reported using the Moderate Sedation codes.

According to CPT, Moderate (Conscious) Sedation includes:

  • Assessment of the patient (not included in intraservice time);
  • Establishment of IV access and fluids to maintain patency, when performed;
  • Administration of agent(s);
  • Maintenance of sedation;
  • Monitoring of oxygen saturation, heart rate and blood pressure; and
  • Recovery (not included in intraservice time).

Moderate sedation is a time based code. Because the Moderate Sedation codes indicate a unit of time of 15 minutes, the ED chart must indicate 10 minutes or more of continuous intra-service (face-to-face) time to report Moderate Sedation.  If the time threshold has not been met, then the code is not reportable.

The continuous intra-service time should be clearly documented in the ED chart.  For these codes, as described by CPT Assistant (February 2006), “Intra-service time starts with the administration of the sedation agent(s), requires continuous face-to-face attendance, and ends at the conclusion of personal contact by the physician providing the sedation.” The patient needs to be continuously monitored and reassessed. An independent, trained observer must be present to assist in monitoring the patient when the physician is both performing the procedure and providing the MCS.  

Documentation should include the name of the procedure, who performed 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 MCS, and total intra-service time.

**Please note: As of January 1, 2017, there are no longer CPT codes that include moderate sedation.  A procedure note should be done anytime moderate sedation is performed.

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