CurrentAlliance HealthPolicy Clinical Coverage Policy No: 1L-2

Moderate (Conscious) Sedation / Procedural Sedation and Analgesia (PSA)

State Medicaid clinical coverage policy defining coverage, eligibility, provider qualifications, supervision, monitoring, documentation, billing codes, and reimbursement rules for moderate (conscious) sedation/PSA for NC Medicaid beneficiaries.

Policy Summary

PayerAlliance Health

PolicyModerate (Conscious) Sedation / Procedural Sedation and Analgesia (PSA)

Policy CodePolicy Clinical Coverage Policy No: 1L-2

Change TypeAmendment (template language updated due to NC Health Choice move to Medicaid)

Effective DateDec 1, 2007

Next Review DateN/A

Key ActionDocument dosage, route, time, effect of drugs; IV fluids; monitoring devices/equipment; staff names/titles; vital signs and level of consciousness at appropriate intervals; and return to baseline at completion.

POLICY UPDATE CHANGES

Policy template language updated due to North Carolina Health Choice Program's move to Medicaid; policy posted 4/15/2023 with an effective date of 4/1/2023.

7Included service components

6Covered CPT/CDT codes listed

0Specific additional covered indications

0Specific not-covered criteria

Medical Necessity Criteria

General Medical Necessity Criteria (Section 3.1)

Medicaid shall cover the procedure, product, or service related to this policy when medically necessary, and:

Criterion A: The procedure, product, or service is individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the beneficiary's needs.
Criterion B: The procedure, product, or service can be safely furnished, and no equally effective and more conservative or less costly treatment is available statewide.
Criterion C: The procedure, product, or service is furnished in a manner not primarily intended for the convenience of the beneficiary, the beneficiary's caretaker, or the provider.

Eligibility Requirements (Section 2.1.1 General)

General eligibility and verification requirements:

Enrollment: An eligible beneficiary shall be enrolled in the NC Medicaid Program.
Verification: Providers shall verify each Medicaid beneficiary's eligibility each time a service is rendered.
Service Restrictions: The Medicaid beneficiary may have service restrictions due to their eligibility category that would make them ineligible for this service.

EPSDT Exception (Section 2.2.1)

For beneficiaries under 21 years, EPSDT may override policy limitations when medically necessary:

EPSDT Coverage: EPSDT covers services medically necessary to correct or ameliorate a defect, physical or mental illness, or a condition identified through screening (includes evaluations by licensed practitioners).
Prior Approval Not Eliminated: EPSDT does NOT eliminate prior approval requirements if the service normally requires prior approval.
Refer also to NCTracks and EPSDT provider resources for additional prior approval information.

Prior Approval (Section 5.1)

Prior approval requirement for moderate sedation/PSA:

No Prior Approval: Medicaid shall not require prior approval for Moderate (Conscious) Sedation.

Components Included (Section 5.3.1)

Moderate sedation/PSA includes the following services, which are not reported separately:

Assessment of the patient.
IV Access: Establishment of IV access and fluids to maintain patency.
Oxygen: Administration of oxygen.
Agent Administration: Administration of agent.
Maintenance of sedation.

Supervision & Provider Responsibilities (Section 5.3.2)

Requirements for who may administer/ supervise moderate sedation/PSA and required actions:

Who May Administer: Sedation shall be administered either by or under the immediate direct supervision of a physician or dentist trained and credentialed to administer and monitor moderate sedation/PSA.
Dental credentialing information referenced to NC Board of Dental Examiners.
History & Physical: Completion of history and physical.
Informed Consent: Completion of informed consent.
Pre-procedure Fasting: Check adequacy of pre-procedure fasting per ASA/AAP guidance: clear liquids 2 hours; breast milk 4 hours; infant formula 6 hours; nonhuman milk 6 hours; light meal 6 hours (consider amount/type).

Monitoring (Section 5.3.3)

Monitoring requirements during procedure and recovery:

Physiologic Monitoring: Continuous monitoring of oxygen saturation and cardiac rate and rhythm; intermittent recording of respiration rate, blood pressure, and level of consciousness.
Supplemental Oxygen: Administration of supplemental oxygen is encouraged for all recipients undergoing moderate sedation/PSA.
Monitoring Staff: Qualified individuals responsible for monitoring may not be engaged in any other activity during the period of moderate sedation/PSA.

Time Factors (Section 5.3.4)

Definition of intraservice time for billing:

Intraservice Time: Intraservice time starts with administration of the sedation agent(s), requires continuous face-to-face attendance, and ends at the conclusion of personal contact by the physician or dentist providing the sedation.

Dental Additional Requirements

Dental providers must also comply with separate dental policy:

Dental Policy Compliance: Dental providers shall additionally comply with Clinical Coverage Policy 4A, Dental Services.

Documentation Requirements (Section 7.2)

Records that must be documented in the recipient's health record:

Drug Documentation: Dosage, route, time, and effect of all drugs used.
IV Fluids and Equipment: Type and amount of IV fluids administered (including blood/products), monitoring devices, or equipment used.
Staff Identification: Name and medical or dental title of staff providing and monitoring moderate sedation/PSA.
Vital Signs Charting: Cardiac rate and rhythm, blood pressure, respiratory rate, oxygen saturation, and level of consciousness charted at intervals appropriate to the level of sedation.

Coding

Covered CPT codes for moderate sedation/PSACPTCovered

99151	Moderate sedation service; more complex services (use per policy)
99152	Moderate sedation service; typical services (use per policy)
99153	Moderate sedation by another physician; typical patient
99155	Moderate sedation service by same physician when additional physician present (two physicians + observer)
99156	Moderate sedation service by same physician when additional physician present (two physicians + observer)
99157	Moderate sedation service by same physician when additional physician present (two physicians + observer)

Covered Dental codes for sedationCDTCovered

D9230	Anxiolysis, sedation — dental
D9239	Analgesia, anxiolysis, inhalation of nitrous oxide
D9243	Intravenous moderate (conscious) sedation/analgesia — each 15 minutes

Billing exclusions / bundling rulesmixedNot Covered

00100-01999	Anesthesia CPT range; 99151-99157 are not billable with these codes
94760-94762	Pulmonary procedure codes; 99151-99157 are not billable with these codes

Operational billing note: Use 99151–99153 for sedation services provided by a single physician plus a trained observer, and use 99155–99157 when two physicians plus a trained observer provide the services. Ensure code selection matches the actual provider configuration to avoid denials.

Provider Actions & Billing Rules

Documentation Required

Record sedation details and monitoring

Document dosage, route, time, and effect of all drugs used; type and amount of IV fluids; monitoring devices/equipment; name and medical/dental title of staff providing and monitoring sedation; cardiac rate and rhythm, blood pressure, respiratory rate, oxygen saturation, and level of consciousness charted at intervals appropriate to the level of sedation; and return to normal level of consciousness, awareness and responsiveness, and airway protective reflexes at completion.

Dosage, route, time, and effect of all drugs used
Type and amount of IV fluids administered (including blood/products)
Monitoring devices or equipment used (pulse oximeter, NIBP, ETCO2 as appropriate, ECG, suction, oxygen)
Name and medical or dental title of staff providing and monitoring sedation
Cardiac rate and rhythm, blood pressure, respiratory rate, oxygen saturation, and level of consciousness charted at appropriate intervals
Return to normal level of consciousness, awareness and responsiveness, and airway protective reflexes at completion

Billing Rule

Use appropriate CPT for provider configuration

Use 99151-99153 for sedation services provided by a single physician and a trained observer; use 99155-99157 when two physicians and a trained observer provide services.

Codes: 99151, 99152, 99153, 99155, 99156, 99157
99151–99153: single physician + trained observer
99155–99157: two physicians + trained observer

Billing Rule

Exclusion with anesthesia and respiratory procedure codes

Moderate sedation codes 99151–99157 are not billable with anesthesia CPT range 00100–01999 or pulmonary procedure codes 94760–94762. Medicaid will not reimburse 99155–99157 when billed in conjunction with Appendix G codes in nonfacility settings.

Conflicting code ranges: 00100-01999 (anesthesia CPT range)
Conflicting code ranges: 94760-94762 (pulmonary procedure codes)
Medicaid non-reimbursement: 99155-99157 when billed with Appendix G codes in nonfacility settings

Prior Authorization

Prior approval not required

No prior approval is required for Moderate (Conscious) Sedation.

Documentation Required

Pre-procedure fasting verification

Check and document adequacy of the pre-procedure fast according to recommended fasting intervals.

Clear liquids: 2 hours
Breast milk: 4 hours
Infant formula: 6 hours
Nonhuman milk: 6 hours (consider amount/type)
Light meal: 6 hours (consider amount/type)

Denial Risk

Coverage denial conditions

Claims may be denied if the beneficiary is ineligible, the service does not meet medical necessity criteria, the service duplicates another provider's service, or the service is experimental, investigational, or part of a clinical trial.

Beneficiary does not meet eligibility requirements
Service does not meet medical necessity criteria
Duplicate service billed by another provider
Service is experimental, investigational, or part of a clinical trial

Background & Definitions

Background: Moderate (conscious) sedation/PSA is defined as a drug-induced depression of consciousness in which patients purposefully respond to verbal commands or light tactile stimulation, maintain a patent airway without intervention, and have adequate spontaneous ventilation—consistent with ASA definitions. The policy describes a continuum of sedation levels from minimal (anxiolysis) through moderate and deep sedation to general anesthesia, noting differences in responsiveness, airway intervention needs, ventilation, and cardiovascular effects. Providers must be qualified and credentialed to recognize and manage deeper-than-intended sedation and be able to 'rescue' patients (interventions to correct hypoventilation, hypoxia, hypotension and return the patient to the intended sedation level). The definition and administration guidance apply to pediatric patients as well, with monitoring and management aligned with AAP/AAPD guidance.

Term	Definition
Moderate Sedation/PSA	Drug-induced depression of consciousness during which patients respond purposefully to verbal commands or light tactile stimulation, no interventions are required to maintain a patent airway, spontaneous ventilation is adequate, and cardiovascular function is usually maintained.
Minimal Sedation (Anxiolysis)	Drug-induced state during which patients respond normally to verbal stimulation; cognitive function and coordination may be impaired, but ventilatory and cardiovascular functions are unaffected.
Deep Sedation/Analgesia	Drug-induced depression of consciousness during which patients are not easily arousable but respond purposefully following repeated or painful stimulation; ventilatory function may be impaired, patients may require assistance to maintain a patent airway, and spontaneous ventilation may be inadequate.
General Anesthesia	Drug-induced loss of consciousness during which patients are not arousable even with painful stimulation; ability to independently maintain ventilatory function is often impaired, airway assistance and positive pressure ventilation may be required, and cardiovascular function may be impaired.

OpenPayer

Moderate (Conscious) Sedation / Procedural Sedation and Analgesia (PSA)

Coverage Summary

Medical Necessity Criteria

Not Covered / Exclusions

Coding

Provider Actions & Billing Rules

Background & Definitions

Revision History