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Moderate vs Minimal Sedation - help please

spinepain

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I have come across a group that is routinely using CPT 99144 to bill for moderate sedation by the surgeon during epidual injections, facet injections, etc. They are typically giving halcion 0.125 - .25 mg +/- vistaril 25 mg po 1 hr before the procedure.

Is this legit? Does oral halcion/vistaril qualify as "moderate sedation"?

Anyone have a good reference for exact definitions of these terms?
 
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lobelsteve

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I saw the ASA table. There's no real substantive difference between the two there.

I found this - http://www.acep.org/PrintFriendly.aspx?id=30480

Looks like IV access is necessary, but nothing about requiring IV meds.

Would "maintenance of sedation" require administration of additional sedation during the procedure?

I think in reading the info in your link:

1. The interservice time requires administration of the medication. THis would be interpreted as actually giving the drug, not the Rx. If somebody wants to get audited via the RAC, and they billed this code and report that they gave the patient an Rx and had them take the pill in the office, well they would have to pay the money back plus a fine. There would be no Anes that would back up moderate sedation via an Rx for some pills.
I'd be glad to testify against somebody clearly committing fraud. Does not pass the sniff test at all.

2. The question would be posed: Why are you monitoring a patient for which you gave an Rx to take? DO you monitor all patients that get these Rx's?
Do not pass go and go directly to jail.
 
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Finally M3

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This was brought up at the coding/practice management seminar here at ISIS

Not really sure I can answer about the actual administered regimen, but OIG/CMS looks for pre-sedation doccumentation of patient demonstrating significant 'pre-procedural anxiety', and that operative note needs to include that 'sedation is titrated to change in comfort/consciousness'.
 
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Aether2000

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I would probably disagree that the route of administration must be IV. For years, sedation was administered nasally, rectally, orally, etc. However, the definition of moderate sedation states the patient will respond to tactile commands, but not verbal commands. It is unlikely an oral route of administration would ever achieve this level of sedation. Furthermore, if the physician is not administering the drug or have it administered by one of his staff, it cannot be considered a billable item. The practice as described here is clearly fraudulant.
 
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spinepain

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This is the best article I have found so far. It's still somewhat vague as to the exact line between minimal and moderate sedation.

http://www.chestjournal.org/content/133/6/1489.full

Does anyone have Appendix G from the CPT manual? Is separate billing for moderate sedation specifically excluded from any of our pain procedures there?
 
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