Coding, Classification & Reimbursement

1.  Moderate Sedation code G0500/ 99153

Posted 06-16-2017 15:15

Has anyone been using moderate sedation codes G0500 - 99153 on Medicare claims?  Is it reimbursed?  Do they cover it for a screening colonoscopy only and not diagnostic or EGD?

I find it confusing that in MLN Matters (MM 10075) the implementation date of these codes is Oct 2, 2017 yet in  MCR Publication (# 100-04 transmittal: 3763) all contractors are asked to pay for them on claims dated Jan 1, 2017 or later.

Any feedback appreciated!



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Anne Ghan
Certified Coder, CCS-P
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2.  RE: Moderate Sedation code G0500/ 99153

Posted 06-16-2017 15:46
​My understanding was that they were to be used after 01/01/2017, I have used them on both diagnostic and screening colonoscopies and upper GI. However, Medicare was approving G0500 but denying 99153 last time I looked. I called them and they didn't have much info, just something along the lines of 99153 being included in the facility charges and not separately payable. Which I didn't quite understand because the G0500 was approved and their own info said to use 99153 for additional time. I submitted a written request for info and have yet to hear back.

Hope that's helpful!

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Katie Stienmetz, CCS

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3.  RE: Moderate Sedation code G0500/ 99153

Posted 06-19-2017 08:12
I just had to do wome research on this myself, because someone had told me that the 99153 only paid on facility side.  This was the best explanation I could find. 

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Tami Hemond
Manager Coding and Provider Education
Alice Peck Day Memorial Hospital
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4.  RE: Moderate Sedation code G0500/ 99153

Posted 06-20-2017 12:32
​Hello Tami,
thank you for sharing this important info.  Was it published on CMS website? Would you mind posting the link?
Anne

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Anne Ghan, CCS-P
Certified Coder
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5.  RE: Moderate Sedation code G0500/ 99153

Posted 06-21-2017 11:53
Not sure where the information came from, but the Medicare RBRVS valuation for five of the six new moderate sedation codes do have a physician work component valuations.  Only the 99153 add-on code has a 0.00 physician work valuation.  The following is the CPT clinical example and procedure description for 99152:

Clinical Example (99152)

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.

Description of Procedure (99152)

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.

This indicates that the moderate sedation services codes does require physician work regardless of the setting.  In addition, all of these codes have a site of service differential meaning Medicare allows payment for these codes at a lower amount in a facility setting than a non-facility setting.   The amount of moderate sedation time is based on the total intra-service time with physician face-to-face presence being one of the determining factors.  How long the patient is monitored by the independent, trained observer pre-sedation administration and after the physician is no longer face-to-face with the patient does not factor into the code selection.

All 6 of the moderate sedation codes have a PC/TC listing of "9" or Not applicable - Concept of a professional/technical component does not apply.

Also, the June 2017 CPT Assistant has a good article on the new Moderate Sedation services codes that you may find helpful.

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Marvel Hammer RN CCS-P CPC
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6.  RE: Moderate Sedation code G0500/ 99153

Posted 09-13-2017 10:27
​Palmetto GBA had a nice explanation of why 99153 is not payable to physician, hope this helps

In the situation in which the physician is performing the surgical/endoscopic procedure and is performing the sedation inside a facility (hospital, ASC), the surgeon can bill only the initial 15 minutes with CPT 99152 (or 99151). These codes include relative value units (RVUs) for the physician work of initiating the sedation. The subsequent intervals of time include no physician work and would not be billed by the surgeon; the work of 99153 represents work of a hospital employee, so is included in reimbursement to the hospital not the surgeon.

 

Note that the Medicare Physician Fee Schedule for CPT code 99153 includes zero RVUs for physician work, and, more important, that the PC/TC Indicator is "3". A PC/TC Indicator of "3" is assigned to codes representing the technical component only, so codes with this indicator are never paid to a professional through Part B when billed from a facility place of service.

 

From <https://www.palmettogba.com/palmetto/providers.nsf/vMasterDID/AK9QUP4025?OpenDocument>



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Allison Evans, RHIA
Coding Manager
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7.  RE: Moderate Sedation code G0500/ 99153

Posted 06-21-2017 11:58
Forgot to include that the G0500 code similarly has a physician work valuation and site of service differential as well.

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Marvel Hammer
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