Question: We are interventional cardiologists and our hospital has taken the position that even though we direct the nurses to give conscious sedation during our procedures, that since an RN is giving the sedation, code 99152 cannot be billed by us. We disagree. The hospital compliance officer claims that moderate sedation is not a billable service when performed by an RN during cardiac catheterizations. Who is correct, us or our hospital?

Moderate Sedation Codes Same Provider (for patient age 5 and older)

99152 - 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; initial 15 minutes of intraservice time, patient age 5 years or older

+99153 - 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)

Answer: It appears your hospital compliance officer has misinterpreted what is meant by “performing” or "administering” moderate sedation when reporting the moderate sedation codes 99152/99153. The nurse’s role is that of a trained observer and the RN is expected to carry out the instructions of the supervising, “administering” physician that is performing/providing the service. The physician’s instructions may include a directive to the nurse to administer the sedating agent. The physician's role is commonly that of an “administrator" or supervisor directing the RN. The physician doesn’t have to administer the moderate sedation drug(s), the physician can supervise the administration of the moderate sedation drug(s) by a RN and the physician is still considered to be performing the service.

In most states, it is beyond the license and scope of practice for an RN to “perform/provide" moderate sedation. The RN is not considered to be performing moderate sedation. The compliance officer’s misunderstanding in this regard is concerning, as it could open the RN up to an inappropriate level of responsibility and liability.

The official AMA CPT/RUC Patient Vignette and Description of Work for 99152 is, as follows:

Vignette: A patient undergoes a procedure that requires moderate sedation. The treating physician will perform both the supported procedure and the moderate sedation service. The physician will supervise and direct an independent, trained observer who will assist in monitoring the patient’s level of consciousness and physiologic status throughout the procedure.

Intra-service

The physician or other qualified health care professional performs presedation patient assessment; supervises or personally provides the administration of the sedating agent, with or without an analgesic; and supervises an independent, trained observer who monitors the patient’s level of consciousness and physiologic status throughout the procedure. The patient is assessed continuously throughout the procedure to achieve an effective and safe level of moderate sedation. Additional doses of the sedating agent(s) are ordered or provided by the physician as needed. The physician’s intraservice time ends when the procedure is complete, the patient is physiologically stable, and face-to-face physician time is no longer required.

In the 2017 Medicare Physician Fee Schedule, the values for the physician work associated with “administering”/supervising moderate sedation was stripped out of all interventional cardiology codes that were valued through the AMA RUC process for which moderate sedation was believed to be “typical”. The only way to recapture this physician work is to accurately and appropriately report the moderate sedation codes (99152, 99153) that went into effect on January 1, 2017.

Alternatively, some cath labs may use CRNAs to administer/perform moderate sedation. CRNAs are specifically trained and accept full responsibility for providing moderate sedation including dose calculations and therefore, can bill separately when performing these services. A CRNA would use codes 99156/99157, used to report moderate sedation when performed by a separate provider from the provider performing the procedure for which moderate sedation is being administered.

Moderate Sedation Codes Same Provider (for patient age 5 and older)

99156 - 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)

99157 - Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes intraservice time (List separately in addition to code for primary service)

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