Most patients who undergo an invasive EP procedure require some sedation in addition to local anesthesia. Levels of sedation are often categorized as minimal sedation (anxiolysis), moderate sedation (conscious), deep sedation, and general anesthesia. In the EP lab, moderate sedation is usually achieved using a combination of narcotics and benzodiazepines administered by a nurse under the direction of the physician performing the procedure. This is usually sufficient to keep a patient comfortable and still during most device implantation and ablation procedures. At times, deep sedation is needed briefly for defibrillation testing and electrical cardioversion. To administer moderate or deep sedation, physicians at most hospitals are required to have specific sedation privileges that come with periodic training and self-assessment. General anesthesia and potent sedatives such as propofol must be administered by an anesthesiologist.
There are also patients in the EP lab who require general anesthesia or monitored anesthesia care (MAC) by an anesthesiologist either because the procedure duration is long, the procedure is guided by a transesophageal echocardiogram, or the patient has high-risk features such as obesity that preclude the safe prolonged administration of sedation without protection of the airway. The need for anesthesia has also increased in EP labs, as procedures have become more complex and patients have more comorbidities. In some EP labs, all sedation is administered by an anesthesia team. Therefore, at many hospitals, the presence of anesthesiologists and nurse anesthetists administering anesthesia in EP labs has increased.
It has always seemed odd that an anesthesiologist can bill for providing MAC during an EP procedure, but an electrophysiologist is not able to bill for providing moderate sedation during an EP procedure that he or she is performing. However, it turns out that the billing codes and fee schedules for EP procedures already account for that additional work required by the EP physician to also administer sedation during the case. Codes in the CPT book that inherently include moderate sedation as part of the procedure actually have a special symbol (•) next to them. So as more anesthesiologists are giving sedation in the EP labs, payors have recognized that they are double-paying for sedation. For this reason, the CPT codes for sedation are being unbundled from the procedures.
The 2017 Current Procedural Terminology (CPT) codebook provides new codes related to sedation this year. The codes are based on how long sedation was given and the age of the patient. Sedation time starts at the time when sedation is administered and ends when the procedure is completed, the patient is stable for recovery, and the physician ends continuous face-to-face time with the patient. The CPT code 99152 is used to bill for sedation for the first 15 minutes, and code 99153 is used for each additional 15 minutes. The official description for CPT code 99152 is “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.”1 Sedation for less than 10 minutes is not billed separately.
Although it has always been the case, it is important to emphasize that administering moderate sedation requires careful monitoring of the patient, including a periodic assessment, further administration of medications to maintain sedation, and monitoring of vital signs; therefore, this requires a dedicated person at the head of the procedure table beyond the circulating nurse.
Unfortunately, these new sedation CPT codes now require additional documentation. The professional billing and coding team at Northwestern Memorial Hospital (NMH) recommended the following documentation be included in the procedure note to support the new codes:
“I was present with the patient for the duration of moderate sedation and supervised staff who had no other duties and monitored the patient for the entire procedure. Details of monitoring are stored in Epic or ‘All Results Flowsheet’ in Cerner.
- Name of independent trained observer:
- Intra-Service start time:
- Intra-Service end time:”
The following wording was accepted as an alternative, since information such as the name of the nurse giving the sedation and the times when sedation was given are already documented in the medical records at NMH:
“I was present with the patient for the duration of moderate sedation and supervised staff who had no other duties and monitored the patient for the entire procedure. Details of sedation and monitoring are entered by the nurse administering the sedation into the EP laboratory electronic record system. Please see the nursing flow sheets for documentation of the name of the independent trained observer, and intra-service start and end times.”
Because reimbursement for invasive EP procedures has always inherently included reimbursement for sedation, payors have figured out that they were paying twice for sedation when an anesthesiologist administers sedation during an EP procedure. For this reason, the CPT codes for sedation have been unbundled. Unfortunately, this unbundling of payments has resulted in additional documentation requirements, and payments for the EP procedures for which moderate sedation was previously considered inherent will be accordingly reduced.1
- American College of Cardiology. CPT Coding Changes For Moderate Sedation in 2017. Published December 7, 2016. Available online at http://www.acc.org/latest-in-cardiology/articles/2016/12/07/08/40/cpt-coding-changes-for-moderate-sedation-in-2017#sthash.Cev8vt05.dpuf. Accessed January 18, 2017.