CurrentBlue Cross Blue Shield - MainePolicy C-25001

Moderate (Conscious) Sedation - Professional and Facility

This reimbursement policy governs separate reimbursement rules for moderate (conscious) sedation provided by professional and outpatient facility providers and applies to commercial members and providers under Blue Cross Blue Shield - Maine.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyModerate (Conscious) Sedation - Professional and Facility

Policy CodePolicy C-25001

Change TypeConsolidation/retirement of prior professional-only policy

Effective DateJul 1, 202618d

Next Review Date

Key ActionDo not bill moderate sedation codes on a UB-04; they will be denied and recovery room revenue code 0710 will not be separately reimbursed when billed with moderate sedation.

SourceLink

POLICY UPDATE CHANGES

Moderate (Conscious) Sedation - Professional (C-08008) will be retired and combined into a new blended policy titled Moderate (Conscious) Sedation - Professional and Facility (C-25001).

Pro+Facpolicy scope change

2017+RVU threshold

Not paidRecovery room (0710)

DeniedUB-04 reporting

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 and facility rules

Moderate sedation services are generally considered included in the reimbursement for professional and outpatient facility providers and are not eligible for separate reimbursement except in specified circumstances.

Professional and outpatient facility moderate sedation services are included in reimbursement and not eligible for separate reimbursement unless provider, state, or federal contracts/requirements indicate otherwise.

Professional components included in reimbursement: assessment (not counted 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/blood pressure, and recovery (recovery not counted in intraservice time).

Moderate sedation administered by a provider who is not performing the associated surgical, diagnostic, or therapeutic procedure is not eligible for reimbursement when performed in a non-facility setting.

RVU-based eligibility

If provider fee schedule uses 2016 or older RVUs: Moderate sedation is not eligible for separate reimbursement when the performing provider reports moderate sedation along with a procedure listed in CPT Appendix G.
If provider fee schedule uses 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 code-specific rules).

Outpatient facility restrictions: the plan will not separately reimburse recovery room services (revenue code 0710) when billed with moderate sedation; moderate sedation codes reported on a UB-04 will be denied; anesthesia revenue codes 037X require an accompanying HCPCS/CPT code when billed with radiology or diagnostic revenue codes.

Specific CPT/HCPCS codes 99151–99157 and G0500 carry detailed eligibility notes (patient age, performing vs non-performing practitioner, additional 15-minute increments, and facility reimbursement exclusion). See coding section for code-level rules.

Policy may be superseded by provider, state, federal, or CMS mandates; services must also meet authorization, medical necessity, and member benefit limitations.

Coding and Reimbursement Eligibility

Moderate sedation CPT/HCPCS codes and eligibility notesmixed

99151	Moderate sedation services provided by the same physician or other qualified healthcare professional performing the diagnostic or therapeutic service; initial 15 minutes of intraservice time, patient younger than 5 years of age; eligible for separate reimbursement when reported with procedure.
99152	Moderate sedation services provided by the same physician or other qualified healthcare professional performing the diagnostic or therapeutic service; initial 15 minutes of intraservice time, patient age 5 years or older; eligible for separate reimbursement when reported with procedure codes that reimburse based on 2017 and later RVUs in the provider's contracted fee schedule; not eligible for facility reimbursement.
99153	Each additional 15 minutes of intraservice time (list separately in addition to code for primary service); eligible for separate reimbursement when reported with procedure codes that reimburse based on 2017 and later RVUs in the provider's contracted fee schedule; not eligible for facility reimbursement.
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; initial 15 minutes of intraservice time, patient younger than 5 years of age; eligible for separate reimbursement when reported with procedure codes that reimburse based on 2017 and later RVUs in the provider's contracted fee schedule; not eligible for facility reimbursement.
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; initial 15 minutes of intraservice time, patient age 5 years or older; eligible for separate reimbursement when reported with procedure codes that reimburse based on 2017 and later RVUs in the provider's contracted fee schedule; not eligible for facility reimbursement.
99157	Each additional 15 minutes of intraservice time by a practitioner other than the one performing the procedure (list separately in addition to code for primary service); eligible for separate reimbursement when reported with procedure codes that reimburse based on 2017 and later RVUs in the provider's contracted fee schedule; not eligible for facility reimbursement.
G0500	Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service; initial 15 minutes of intraservice time, patient age 5 years or older; not eligible for facility reimbursement.

RVU-based separate reimbursement threshold - inv-03: RVU-based separate reimbursement threshold

Eligibility by RVU scheduleProcedures reimbursed using 2017 and later RVUs are eligible for separate moderate sedation reimbursement; procedures using 2016 and older RVUs are not eligible for separate reimbursement and are bundled per CPT Appendix G.

Same-provider reporting ruleWhen the same provider reports both the procedure and the moderate sedation, separate reimbursement is allowed only if the provider's contracted fee schedule reimburses the procedure using 2017 or later RVUs.

Non-facility restrictionModerate sedation administered by a provider who is not performing the associated procedure is not eligible for reimbursement when performed in a non-facility setting.

Facility reimbursement noteSeveral moderate sedation codes (e.g., 99152, 99153, 99155, 99156) are noted as not eligible for facility reimbursement even when eligible for separate professional reimbursement under 2017+ RVU schedules.

Reference to CPT Appendix GProcedures listed in CPT Appendix G are specifically referenced as bundled with moderate sedation for providers using 2016 and older RVU-based fee schedules.

Provider Actions and Billing Rules

Billing Rule

General reimbursement and billing restrictions for moderate sedation

The policy states that moderate sedation services listed are considered included in reimbursement and are not eligible for separate reimbursement except when provider, state, or federal contracts require otherwise. The plan will deny moderate sedation codes when reported on a UB-04 and will not separately reimburse recovery room services (revenue code 0710) when billed with moderate sedation. Anesthesia revenue codes 037X billed with radiology or diagnostic revenue codes must include an accompanying HCPCS/CPT code.

Moderate sedation services are included in reimbursement and not eligible for separate reimbursement unless provider, state, or federal contracts/requirements indicate otherwise. (Chunk 1)
Recovery room services (rev code 0710) will not be separately reimbursed when billed with moderate sedation. (Chunk 3)
Moderate sedation codes reported on a UB-04 will be denied. (Chunk 3)
Anesthesia revenue codes 037X require an accompanying HCPCS/CPT code when billed with radiology or diagnostic revenue codes. (Chunk 3)

Definitions

inv-05: Independent trained observer

DefinitionIndependent trained observer: An 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.

ContextRequired presence for certain moderate sedation codes when the sedation supports a diagnostic or therapeutic service.

inv-06: Intraservice time

DefinitionIntraservice time: The time within a single episode of care used in 15-minute intervals to determine the appropriate CPT code for moderate sedation.

Timing startStarts with the administration of the sedation agent(s) and continues with direct (face-to-face) attendance.

Timing endEnds at the close of personal contact with the patient by the physician or other qualified healthcare professional providing the sedation.

Interval incrementsReported in 15-minute increments (initial 15 minutes and additional 15-minute units for extended intraservice time).

inv-07: Moderate (Conscious) Sedation

Clinical definitionModerate (Conscious) Sedation: Drug-induced depression of consciousness during which patients respond purposefully to verbal commands.

Monitoring requirementRequires monitoring of oxygen saturation, heart rate, and blood pressure during administration and maintenance of sedation.

Observer requirementAn independent trained observer may be required to assist in monitoring the patient's level of consciousness and physiological status for certain services.

inv-08: RVUs

DefinitionRelative Value Units (RVUs): 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 policyThe policy uses the provider's contracted fee schedule RVU base (2016 and older vs. 2017 and later) to determine separate reimbursement eligibility for moderate sedation.

ImpactProcedures reimbursed under 2016 and older RVUs are generally bundled with moderate sedation; 2017+ RVU schedules may permit separate reimbursement when other criteria are met.

OpenPayer

Moderate (Conscious) Sedation - Professional and Facility

Coverage Criteria

Coding and Reimbursement Eligibility

Provider Actions and Billing Rules

Definitions