CurrentBlue Cross Blue Shield - NevadaPolicy C-08008

Moderate (Conscious) Sedation reimbursement

Defines Anthem/Blue Cross Blue Shield Nevada reimbursement and reporting guidelines for moderate (conscious) sedation, including when moderate sedation is included in procedure reimbursement and when it may be eligible for separate payment based on provider fee schedule RVUs. Affects participating and non‑participating professional providers and facilities billing Anthem members.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyModerate (Conscious) Sedation reimbursement

Policy CodePolicy C-08008

Change TypeClarified (RVU-based reimbursement eligibility)

Effective DateNov 19, 2021

Next Review DateN/A

Key ActionServices must meet authorization and medical necessity guidelines and be billed using standard CPT/HCPCS/revenue codes supported by the medical record.

SourceLink

POLICY UPDATE CHANGES

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

Policy history entry 12/29/2023 indicates review approved with no changes.

2017RVU breakpoint

99151-99157Primary CPT codes

6 pagesDocument length

12/29/2023

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.

Coverage Criteria for Moderate Sedation

Coverage criteria for moderate sedation

Reimbursement determination depends on who provides the sedation and which RVU baseline the provider's contracted fee schedule uses.

ALL of the following

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

ALL of the following

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

ANY of the following

If the provider's contracted fee schedule uses 2016 or older RVUs: moderate sedation is not eligible for separate reimbursement when reported with a procedure listed in CPT® Appendix G (i.e., the moderate sedation codes are bundled).
If the provider's contracted fee schedule uses 2017 or later RVUs: moderate sedation codes (99151–99157) reported by the same provider with the procedure may be eligible for separate reimbursement.

ALL of the following

Some moderate sedation codes require the presence of an independent trained observer to assist in monitoring the patient's level of consciousness and physiological status; age‑based distinctions are specified in code descriptors.

ALL of the following

Providers must use industry standard CPT/HCPCS/revenue codes and support billed services in the medical record; services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis; Anthem may recover or deny payments if coding or billing guidelines are not followed.

Relevant Codes and RVU Breakpoint

Moderate sedation CPT codesCPT

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; initial 15 minutes of intraservice time.
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.
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 intraservice time.

RVU policy breakpoint (moderate sedation reimbursement)

Policy breakpoint year2017

When fee schedule uses 2017 or later RVUsModerate sedation reported by the same provider with a procedure may be eligible for separate reimbursement.

When fee schedule uses 2016 or older RVUsModerate sedation is not eligible for separate reimbursement and is bundled with specified procedures (Appendix G behavior).

Effect on billingBundled codes are not eligible for modifier override when fee schedule uses 2016 or older RVUs.

Authorization, Billing and Documentation Requirements

Prior Authorization

Authorization, billing and documentation requirements for moderate sedation

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis. Providers must follow proper billing and submission guidelines using industry‑standard CPT, HCPCS and/or revenue codes, and ensure billed services are fully supported in the medical record or office notes. Anthem may recover/recoup payment or reject/deny claims if coding, billing or current reimbursement policies are not followed.

Obtain any required prior authorization and document medical necessity for the procedure and associated moderate sedation.
Bill using appropriate CPT/HCPCS/revenue codes (e.g., 99151–99157 where applicable) and ensure documentation supports time‑based reporting and any observer requirements.
Maintain medical record entries (assessment, administration, monitoring, recovery) to support the services billed; be aware Anthem may recover or deny payments for noncompliance.

Definitions

Independent trained observer

TermIndependent trained observer

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

RoleAssists in monitoring the patient’s level of consciousness as required by certain moderate sedation codes.

Intraservice time

TermIntraservice time

DefinitionThe time within a single episode of care counted in 15‑minute intervals to determine the appropriate CPT code for moderate sedation.

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