CurrentBlue Cross Blue Shield - MainePolicy C-08008

Moderate (Conscious) Sedation - Professional

Defines Anthem Blue Cross Blue Shield - Maine reimbursement and reporting guidelines for professional moderate (conscious) sedation services and explains when separate reimbursement is allowed, affecting providers billing commercial member plans.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyModerate (Conscious) Sedation - Professional

Policy CodePolicy C-08008

Change TypeRevised (two-tier RVU rule) + added definitions

Effective DateNov 19, 2021

Next Review DateN/A

Key ActionEnsure services meet authorization and medical necessity requirements and follow state/provider contract rules when billing for moderate sedation.

SourceLink

POLICY UPDATE CHANGES

Policy language updated in favor of a two-tiered policy based on the contracted fee schedule of the provider.

A definition was added for RVUs and additional language was added to the definition of intraservice time.

CMS was added as a reference.

2-tierreimbursement approach

5+CPT moderate sedation codes referenced

Included listincluded components

NationalReferences

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyModerate (Conscious) Sedation - Professional

Policy CodePolicy C-08008

Change TypeRevised (two-tier RVU rule) + added definitions

Effective DateNov 19, 2021

Next Review DateN/A

Key ActionEnsure services meet authorization and medical necessity requirements and follow state/provider contract rules when billing for moderate sedation.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Separate reimbursement criteria

Covered when ALL of the following rules are met:

ALL of the following

Assessment of the patient (assessment time is not included in intraservice time).
Establishment of IV access and fluids when performed to maintain patency.
Administration of agent(s).
Maintenance of sedation.
Monitoring of oxygen saturation, heart rate and blood pressure.
Recovery (recovery time is not included in intraservice time).

Moderate sedation administered by a physician or other qualified health care professional who is NOT performing the associated surgical, diagnostic, or therapeutic procedure is not eligible for reimbursement when administered in a non-facility setting.

Fee-schedule dependent reimbursement

If the provider's contracted fee schedule is based on RVUs prior to 2017, moderate sedation is NOT eligible for separate reimbursement when the performing provider reports moderate sedation along with a procedure listed in former CPT Appendix G (these procedure codes automatically bundled with moderate sedation).
See Appendix G (CPT prior to 2017) bundling guidance.
If the provider's contracted fee schedule is based on 2017-or-later RVUs, moderate sedation IS eligible for separate reimbursement when the same provider reports both the procedure and the moderate sedation, subject to the contracted fee schedule behavior.

Related coding note: CPT codes 99151–99157 (initial and additional 15-minute intraservice intervals) include comments that eligibility for separate reimbursement depends on whether the associated procedure codes reimburse based on 2017-or-later RVUs in the provider's contracted fee schedule; codes require reporting of intraservice time and, for some codes, the presence of an independent trained observer.

CPT Codes and Fee Schedule Rule

Moderate (Conscious) Sedation CPT codesCPTCovered

99151	Moderate sedation services provided by the same physician or other qualified healthcare professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient younger than 5 years of age.
99152	Moderate sedation services provided by the same physician or other qualified healthcare professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older.
99153	Moderate sedation services provided by the same physician or other qualified healthcare professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service).
99155	Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified healthcare professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient younger than 5 years of age.
99156	Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified healthcare professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient age 5 years or older.
99157	Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified healthcare professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes of intraservice time (List separately in addition to code for primary service).

Fee schedule RVU rule

Rule summarySeparate reimbursement for moderate sedation is allowed only when the provider's contracted fee schedule uses 2017-or-later RVUs; not allowed for providers using pre-2017 RVU-based fee schedules when billed by the same provider for certain procedure codes.

When not eligibleFor providers using fee schedules based on RVUs prior to 2017, moderate sedation is not eligible for separate reimbursement when reported along with a procedure listed in CPT Appendix G.

When eligibleFor providers using fee schedules based on 2017-or-later RVUs, moderate sedation is eligible for separate reimbursement when the same provider reports both the procedure and the moderate sedation.

Authorization, Medical Necessity, and Billing Actions

Prior Authorization

Authorization, medical necessity, and applicable contracts

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and the member's state of residence; follow applicable provider, state, or federal contracts which may supersede this policy.

Use industry-standard, compliant CPT/HCPCS/Revenue codes and ensure billed codes are fully supported in the medical record or office notes.
Follow proper billing and submission guidelines; failure to follow guidelines may result in claim rejection/denial or recovery/recoupment of payments.

Definitions and Operational Terms

Independent trained observer

DefinitionAn individual who is qualified to monitor the patient during the procedure.

RoleAssists in monitoring the patient's level of consciousness and physiological status during moderate sedation (see related CPT code descriptions).

ContextRequired presence is referenced in CPT code descriptions for moderate sedation when provided by the same clinician performing the procedure.

Intraservice time

DefinitionThe time within a single episode of care, used in 15-minute intervals to determine the appropriate CPT code to report moderate sedation services.

StartBegins with the administration of the sedation agent(s).

Scope and endContinues with direct (face-to-face) attendance and ends at the close of personal contact by the provider; used to calculate initial and additional 15-minute reporting intervals.

Moderate (Conscious) Sedation

DefinitionDrug-induced depression of consciousness during which patients respond purposefully to verbal commands.

Clinical implicationUsed to classify sedation level for CPT coding of moderate (conscious) sedation services.

Associated requirementsWhen provided by the same clinician performing the procedure, certain CPT descriptions note the requirement for an independent trained observer.

RVUs

DefinitionRelative Value Units (RVUs) are the units of measurement for CMS's resource-based relative value scale (RBRVS) used to define the value of a service or procedure relative to others.

Use in policyProvider contracted fee schedules based on pre-2017 versus 2017-or-later RVUs determine eligibility for separate reimbursement of moderate sedation.

Reference scopeRVU edition referenced in coding eligibility and CPT code comments affecting reimbursement treatment.

OpenPayer

Moderate (Conscious) Sedation - Professional

Separate Reimbursement Rules

CPT Codes and Fee Schedule Rule

Authorization, Medical Necessity, and Billing Actions

Definitions and Operational Terms