Documentation of Moderate Sedation

With regard to documentation of moderate sedation, beginning January 1, 2017, we would suggest documenting the duration of moderate sedation services. Intraservice time should be documented based on the specific number of minutes, as opposed to a range of time, to meet all payer requirements. Please note that the moderate sedation intraservice time will likely be different than the intraservice time of the underlying procedure. If the physician does not document his/her intraservice time or if the time is less than 10 minutes, the service is not reportable.

Please let us know if you have any additional questions.  Also, please keep us posted on the claims process, we would be interested to know how they adjudicate.