Q&A: Billing moderate sedation for a physician

Q: Does a physician physically need to inject a sedating agent to justify the use of a moderate sedation code?

A: The use of the moderate sedation code depends on whether the physician is present during the administration of the sedating agent. The codes are based on face-to-face time with the physician, if he or she is the one performing the procedure. If a nurse administers the sedative, then the physician would have to be supervising the nurse. Remember, face-to-face time is calculated using continuous face-to-face time with the patient and the time the sedating agent is administered.

Editor’s note: Stacie L. Buck, RHIA, CCS-P, CIRCC, RCC, president and senior consultant for RadRx of Stuart, Florida, and author of Cracking the IR Code: Your Comprehensive Guide for Mastering Interventional Radiology, answered this question.

This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment. Need expert advice? Email your questions for consideration in the Revenue Cycle Daily Advisor. Note: We do not guarantee that all questions will be answered.