Moderate (Conscious) Sedation reimbursement
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This document provides reimbursement policy guidance for billing and reimbursement of moderate (conscious) sedation services for Blue Cross Blue Shield - Wisconsin members, including billing code usage and requirements for documentation and medical necessity.
No material clinical or coverage changes in this revision.
Coverage Conditions
Coverage conditions
Coverage is contingent on member benefit plan, medical necessity, authorization, and proper documentation.
If coding or policy requirements are not followed
- Claim may be rejected or denied
- We may recover and/or recoup claim payment
Billing and Coding Guidance
| No codes listed |
Authorization, Medical Necessity, and Provider Requirements
Authorization and medical necessity required
Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and to the member's state of residence; coverage determination alone does not guarantee reimbursement.
- Confirm the service is covered under the member's benefit plan before billing.
- Obtain any required prior authorization when the member's plan requires it.
- Ensure the procedure and diagnosis meet medical necessity criteria for the member's state of residence.
Definitions and Documentation Requirements
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