Q&A: Are new moderate sedation codes packaging into APC rates?

Q: The new conscious moderate sedation codes (99152-99157) have been assigned status indicator N (no additional payment, payment included in line items with APCs for incidental service) indicators. Please clarify if they are actually bundled into the APC payment.

Also, we read an article which states that the 99153 and 99157 add-on code cannot be billed by the surgeon because they have no work relative value units (RVU). We feel that this is in error, but there has not been any retraction or correction of the information in the article. Is it true that surgeons cannot bill the add-on codes?

A: Under the OPPS, the new moderate sedation codes (99151-99157) are assigned to status indicator N and are packaged into the APC payment for the procedure. While the codes are different for 2017, moderate sedation has been a packaged service for many years when reported separately. Until the 2017 CPT code update, these services were inherent to many other services, including surgery and endoscopy procedures.

There is nothing that states or implies that physicians cannot report the moderate sedation add-on codes. CMS explains in detail the rationale for their methodology of how they assigned the final RVU for moderate sedation codes in the Medicare Physician Fee Schedule final rule for CY 2017, published in the Federal Register on November 15, 2016, beginning on page 80339:

Therefore, for CY 2017, we are finalizing work RVUs for the moderate sedation codes as follows:

• Work RVU of 0.50 for CPT code 99151
• Work RVU of 0.25 for CPT code 99152
• Work RVU of 1.90 for CPT code 9915;
• Work RVU of 1.65 for CPT code 99156
• Work RVU of 1.25 for CPT code 99157

These RVUs correspond to what is published in the Medicare Physician Fee Schedule PRRVU17 file. Under the Medicare Physician Fee Schedule, CPT code 99153 is the only code with a work RVU of zero. CMS stated in the final rule:

We note that CPT code 99153 is a PE only code and we are finalizing the proposed PE inputs for CPT code 99153, as well as finalizing the proposed PE inputs for all other codes in this family without modification.

Editor’s note: Denise Williams, RN, CPC-H, senior vice president of revenue integrity services at Revant Solutions, in Fort Lauderdale, Florida, answered this question.

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