REIMBURSEMENT POLICY
CMS-1500
RETIRED
Moderate Sedation Policy
Policy
Number
2016R0035A
Annual
Approval
Date
7/13/2016
Approved
By
Payment Policy Oversight
Committee
IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY
You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure
that you are reimbursed based on the code or codes that correctly describe the health care services
provided. UnitedHealthcare Community Plan reimbursement policies uses Current Procedural
®
Terminology (CPT *), Centers for Medicare and Medicaid Services (CMS) or other coding guidelines.
References to CPT or other sources are for definitional purposes only and do not imply any right to
reimbursement.
This reimbursement policy applies to all health care services billed on CMS 1500 forms and, when
specified, to those billed on UB04 forms. Coding methodology, industry-standard reimbursement logic,
regulatory requirements, benefits design and other factors are considered in developing reimbursement
policy.
This information is intended to serve only as a general reference resource regarding UnitedHealthcare
Community Plan’s reimbursement policy for the services described and is not intended to address every
aspect of a reimbursement situation. Accordingly, UnitedHealthcare Community Plan may use reasonable
discretion in interpreting and applying this policy to health care services provided in a particular case.
Further, the policy does not address all issues related to reimbursement for health care services provided
to UnitedHealthcare Community Plan enrollees.
Other factors affecting reimbursement supplement, modify or, in some cases, supersede this
policy. These factors include, but are not limited to: federal &/or state regulatory requirements, the
physician or other provider contracts, the enrollee’s benefit coverage documents, and/or other
reimbursement, medical or drug policies.
Finally, this policy may not be implemented exactly the same way on the different electronic claims
processing systems used by UnitedHealthcare Community Plan due to programming or other constraints;
however, UnitedHealthcare Community Plan strives to minimize these variations.
UnitedHealthcare Community Plan may modify this reimbursement policy at any time by publishing a new
version of the policy on this Website. However, the information presented in this policy is accurate and
current as of the date of publication.
UnitedHealthcare Community Plan uses a customized version of the Optum Claims Editing System
known as iCES Clearinghouse to process claims in accordance with UnitedHealthcare Community Plan
®
reimbursement policies.*CPT is a registered trademark of the American Medical Association
Proprietary information of UnitedHealthcare Community and State
Copyright 2016 United HealthCare Services, Inc.
Application
This reimbursement policy applies to UnitedHealthcare Community Plan Medicaid and Medicare
products.
This reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form
(a/k/a CMS-1500) or its electronic equivalent or its successor form. This policy applies to all products and
all network and non-network physicians and other qualified health care professionals, including, but not
limited to, non-network authorized and percent of charge contract physicians and other qualified health
care professionals. This policy applies to claims with dates of service prior to 1/1/2017. For claims with
dates of service on or after 1/1/2017 refer to the CCI Editing Policy and the Rebundling Policy.
Payment Policies for Medicare & Retirement and Employer & Individual please use this link.
Medicare & Retirement Policies are listed under Medicare Advantage Reimbursement Policies.
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REIMBURSEMENT POLICY
CMS-1500
Employer & Individual are listed under Reimbursement Policies-Commercial.
Policy
Overview
Current Procedural Terminology (CPT®) defines Moderate (conscious) Sedation as a drug induced
depression of consciousness during which patients respond purposefully to verbal commands, either
alone or accompanied by light tactile stimulation. In addition, no interventions are required to maintain a
patent airway and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.
Moderate Sedation does not include Minimal Sedation (anxiolysis), deep sedation or monitored
anesthesia care (00100-01999).
Moderate Sedation services reported by the Same Physician or Other Qualified Health Care Professional
reporting the diagnostic or therapeutic procedure, are separately reimbursable services when submitted
under CPT codes 99143-99145 except when reported with the procedures noted below.
In a facility setting, Moderate Sedation services performed by a second physician or other qualified health
care professional are separately reimbursable services when submitted under CPT codes 99148-99150.
In a non-facility setting, CPT codes 99148-99150 will not be reimbursed when the same or different
physician or other qualified health care professional also reports a code listed in Appendix G of the CPT
codebook.
Note: Based on their intended use, Moderate Sedation codes 99148-99150 would not be reported with
diagnostic or therapeutic procedures.
UnitedHealthcare Community Plan’s reimbursement policy for Moderate Sedation services is based on
methodologies used and recognized by the Centers for Medicare and Medicaid Services (CMS) National
Correct Coding Initiative (NCCI) edits and Policy Manual, and CPT codebook guidelines.
For purposes of this policy, Same Physician or Other Qualified Health Care Professional is defined as the
same individual rendering health care services reporting the same Federal Tax Identification number.
Reimbursement Guidelines
Attending Physician (99143-99145)
UnitedHealthcare Community Plan will allow separate reimbursement for Moderate Sedation services
reported using CPT codes 99143-99145 when provided by the Same Physician or Other Qualified Health
Care Professional reporting the diagnostic or therapeutic procedure except when reported with:
1) Procedures listed in Appendix G of the CPT book
2) Anesthesia procedures (CPT codes 00100-01999)
3) CPT and HCPCS codes that are part of CMS NCCI edits
These procedures include Moderate Sedation as an inherent part of providing the service. Refer to the list
below for a comprehensive listing of the non-anesthesia procedures that include Moderate Sedation and
for which CPT codes 99143-99145 will not be considered separately.
UnitedHealthcare Community Plan Procedures that include Moderate Sedation Codes (99143-99145)
Note: Procedure codes that are listed in Appendix G of the CPT book that are also identified on the
National Physician Fee Schedule (NPFS) as Status B are addressed in the B Bundle Codes Policy.
Second Physician (99148-99150)
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REIMBURSEMENT POLICY
CMS-1500
Moderate Sedation services performed by a second physician or other qualified health care professional
(who is not performing the diagnostic or therapeutic procedure that the sedation supports), should be
reported as CPT codes 99148-99150.
Reimbursement of CPT codes 99148-99150 based on the place of service is as follows:
Non-facility setting
According to the AMA “When moderate sedation is performed in the non-facility setting, the efforts of the
second physician are not reported with the codes in Appendix G because moderate sedation is included
in these codes. Therefore, it would not be appropriate to separately report for moderate sedation.” Based
on AMA guidelines, UnitedHealthcare Community Plan will reimburse CPT codes 99148-99150 in a nonfacility setting except when a procedure code listed in Appendix G of the CPT codebook is also reported
on the same date of service by the same or different physician or other qualified health care professional.
Facility setting
Moderate Sedation services reported as CPT codes 99148-99150 that are performed by a second
physician or other qualified health care professional in a facility place of service (see listing below) are
eligible for reimbursement.
For purposes of this policy a facility place of service would include any of the following locations:
19 Off Campus-Outpatient Hospital
21 Inpatient Hospital
22 On Campus-Outpatient Hospital
23 Emergency Room-Hospital
24 Ambulatory Surgical Center
26 Military Treatment Facility
31 Skilled Nursing Facility
34 Hospice
41 Ambulance - Land
42 Ambulance - Air or Water
51 Inpatient Psychiatric Facility
52 Psychiatric Facility - Partial Hospitalization
53 Community Mental Health Center
56 Psychiatric Residential Treatment Center
61 Comprehensive Inpatient Rehabilitation Facility
For additional information, refer to the Questions and Answers section, Q&A #1 and #3.
Drug Reimbursement
The cost of the drug used in Moderate Sedation, if supplied by the physician in a location other than
inpatient/outpatient hospital, emergency room or ambulatory surgical center, is reimbursable at the
appropriate fee schedule or contracted rate. For additional information on drugs supplied in an
inpatient/outpatient hospital, emergency room or ambulatory surgical center, refer to the Supply Policy.
State Exceptions
Wisconsin
CPT codes 99143-99149 are not reimbursable due to Wisconsin Regulations.
Wisconsin has a state specific list of codes that are included in the Non
Covered Codes policy.
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REIMBURSEMENT POLICY
CMS-1500
Definitions
Minimal Sedation
Minimal Sedation (anxiolysis) is a drug-induced state during which patients
respond normally to verbal commands. Although cognitive function and
coordination may be impaired, ventilatory and cardiovascular functions are
unaffected.
Moderate Sedation
Moderate (conscious) Sedation is a drug induced depression of
consciousness during which patients respond purposefully to verbal
commands, either alone or accompanied by light tactile stimulation. No
interventions are required to maintain a patent airway, and spontaneous
ventilation is adequate. Cardiovascular function is usually maintained.
Moderate Sedation does not include Minimal Sedation (anxiolysis), deep
sedation, or monitored anesthesia care (CPT codes 00100-01999).
Same Physician or
Other Qualified Health
Care Professional
The same individual rendering health care services reporting the same
Federal Tax Identification number.
Questions and Answers
Q: A second physician has rendered Moderate Sedation in a non-facility setting for a procedure
listed in Appendix G of the CPT codebook reported by the attending physician. Will the second
physician’s services be separately reimbursed?
1
A: No. When Moderate Sedation is performed in the non-facility setting, the efforts of the second
physician are not reported with the codes in Appendix G because Moderate Sedation is included in
these codes. In a non-facility setting the second physician is considered the "trained observer," and
should be reimbursed by the attending physician.
Q: In the policy overview it states: Moderate Sedation does not include Minimal Sedation
(anxiolysis). What are some examples of Minimal Sedation?
2
A: According to the report titled Practice Guidelines for Sedation and Analgesia by NonAnesthesiologists (obtained from the ASA website), "Examples of minimal sedation include
peripheral nerve blocks, local or topical anesthesia, and either (1) less than 50% nitrous oxide
(N2O) in oxygen with no other sedative or analgesic medications by any route, or (2) a single, oral
sedative or analgesic medication administered in doses appropriate for the unsupervised treatment
of insomnia, anxiety, or pain."
Q: Why would it be appropriate to report CPT codes 99148-99150 for an Appendix G procedure
when performed in a facility place of service?
3
A: According to the AMA, the provision of sedation by a second provider would not be the normal
course of action and that implies a different intensity of work for these services than would be the
case when it is inherent to the procedure. This work would properly be performed in a facility, not a
non-facility, place of service
Codes
CPT code section
99143
Moderate sedation services (other than those services described by codes
00100-01999) 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 patients level of consciousness and
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REIMBURSEMENT POLICY
CMS-1500
physiological status; younger than 5 years of age, first 30 minutes intraservice time
99144
Moderate sedation services (other than those services described by codes
00100-01999) 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 patients level of consciousness and
physiological status; age 5 years or older, first 30 minutes intra-service time
99145
Moderate sedation services (other than those services described by codes
00100-01999) 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 patients level of consciousness and
physiological status; each additional 15 minutes intra-service time (List
separately in addition to code for primary service)
99148
Moderate sedation services (other than those services described by codes
00100-01999), provided by a physician or other qualified health care
professional other than the health care professional performing the diagnostic
or therapeutic service that the sedation supports; younger than 5 years of
age, first 30 minutes intra-service time
99149
Moderate sedation services (other than those services described by codes
00100-01999), provided by a physician or other qualified health care
professional other than the health care professional performing the diagnostic
or therapeutic service that the sedation supports; age 5 years or older, first
30 minutes intra-service time
99150
Moderate sedation services (other than those services described by codes
00100-01999), provided by a physician or other qualified health care
professional other than the health care professional performing the diagnostic
or therapeutic service that the sedation supports; each additional 15 minutes
intra-service time (List separately in addition to code for primary service)
Attachments: Please right-click on the icon to open the file.
UnitedHealthcare
Community Plan
Procedures that include
Moderate Sedation
Codes (99143-99145)
This comprehensive list identifies the codes contained in Appendix G of the
CPT book and codes that are part of CMS NCCI edits for procedures that
include Moderate Sedation services. The codes on this list do not allow
separate reimbursement for Moderate Sedation codes 99143-99145.
Resources
Individual state Medicaid regulations, manuals & fee schedules
®
American Medical Association, Current Procedural Terminology ( CPT ) and associated publications and
services
Proprietary information of UnitedHealthcare Community Plan. Copyright 2017 United HealthCare Services, Inc. 2016R0035A
REIMBURSEMENT POLICY
CMS-1500
Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and
services
Centers for Medicare and Medicaid Services, National Correct Coding Initiative (NCCI) publications
Publications and services of the American Society of Anesthesiologists (ASA)
History
1/1/2017 Policy Retired
7/13/2016 Policy Approval Date Change (no new version)
1/1/2016 Annual Policy Version Change
Policy Verbiage Change: Updated the Reimbursement Guidelines section to add place of
service 19
Policy List Change: Updated Procedures that include Moderate Sedation Codes (9914399145)
History Section: Entries prior to 1/1/2014 archived
3/1/2015 Application Section: Removed reference to location of policy for Mississippi Chip (no new
version)
1/1/2015 Annual Version Change
History Section: Entries prior to 1/1/13 archived
11/15/2014 Policy Verbiage Change: Updated Overview and Reimbursement Guidelines section for CPT
codes 99148-99150 (Second Physician)
Questions and Answers Section: Updated Q&A #1; added Q&A #3
State Exceptions Section Updated: Verbiage change for Wisconsin
9/8/2014 Resources Section: Updated (no new version)
Application Section: Updated
8/4/2014 Application Section: Removed reference to location of policy for Florida Medicaid and Rhode
Island Medicaid, added “including, but not limited to” verbiage, and added verbiage stating
this policy applies to UnitedHealthcare Community Plan Medicaid and Medicare products.
3/31/2014 Disclaimer: Revised
2/16/2014 Policy List Change: UnitedHealthcare Community Plan Procedures that include Moderate
Sedation Codes (99143-99145)
1/27/2014 Annual renewal of policy approved by United HealthCare Community & State Payment
Policy Committee
1/7/2014 Policy List Change: UnitedHealthcare Community Plan Procedures that include Moderate
Sedation Codes (99143-99145)
1/1/2014 Annual Version Change
Policy List Change:
Policy List Name Change: Codes that include CPT codes 99143-99145 replaced with
Procedures that include Moderate Sedation Codes (99143-99145)
Policy Verbiage Change: Added “diagnostic or therapeutic” procedure, removed “medical or
surgical” procedure; all defined terms capitalized
Definitions: all defined terms capitalized
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