Physicians taking advantage of new unbundled codes for billing moderate or conscious sedation are receiving denials from Medicare for one of them. That code, 99153, which is the add-on code for additional time spent administering conscious sedation by a provider who’s also performing the primary service, has been denied by Medicare when the service was performed in a facility setting.
In an FAQ about the denials, Medicare Administrative Contractor WPS-GHA said the denial is correct since “physician’s work for this moderate sedation service is paid under the primary procedure code (99151 or 99152) only.” The 99153 code, they wrote, is “for the reimbursement of the additional practice expense of this moderate sedation service only. There are no work RVUs assigned to this code. Since a physician would not be expected to incur any practice expenses when providing a service in a facility setting, codes that reimburse for the practice expense only are not reimbursable to the physician when the service is performed in a facility setting.”
The three procedures mentioned above were actually half of six new codes introduced in 2017 for billing moderate or conscious sedation. These codes were created after the service was unbundled from many surgical procedure codes. The Centers for Medicare and Medicaid Services (CMS) included the new codes in the 2017 Medicare Physician Fee Schedule, saying, “This coding change [provides] for payment for moderate sedation services only in cases where it is furnished.”
Four of the six codes allow providers to indicate who performs the sedation, whether that provider also performed the primary procedure, how long the sedation service lasted, and the age of the patient. The remaining two of the codes are considered “add-on” codes to indicate additional time spent administering the sedation.
| Code | Provider Performing Sedation and Primary Service | Code | Provider Performing Sedation but not Primary Service |
| 99151 | “initial 15 minutes of intraservice time, patient younger than 5 years of age” | 99155 | “initial 15 minutes of intraservice time, patient younger than 5 years of age” |
| 99152 | “initial 15 minutes of intraservice time, patient age 5 years or older” | 99156 | “initial 15 minutes of intraservice time, patient age 5 years or older” |
| 99153 | “each additional 15 minutes intraservice time (list separately in addition to code for primary service)” | 99157 | “each additional 15 minutes intraservice time (list separately in addition to code for primary service)” |
Though Medicare is denying 99153 in the facility setting, other payers are paying for the add-on code, so providers should continue to code for and bill the procedure. As well, most payers, including Medicare, do seem to be paying for the 99157 add-on code in the facility setting, which stands to reason since work RVUs have been assigned to that code.
According to CIPROMS Coding Liaison Cara Geary, the bigger win with the new conscious sedation codes is the shorter intraservice time for billing. Previously the intraservice time for conscious sedation was 30 minutes, and at least 16 minutes had to pass before the code could be billed per CPT guidelines. The new codes have a 15-minute intraservice time, and CPT guidelines indicate that physicians can bill sedation if 10 or more minutes pass. Additionally, to bill an add-on code, only 23 minutes of intraservice time is needed.
For more information about Medicare’s denial of 99153, visit the WPS-GHA FAQ on the issue.
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