CurrentWellpointPolicy C-25001

Moderate (Conscious) Sedation - Professional and Facility

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Governs separate reimbursement and bundling rules for moderate conscious sedation billed by professional providers and outpatient or inpatient facilities under Wellpoint commercial plans in Florida, Maryland, Texas, and Washington.

Policy Summary

PayerWellpoint

PolicyModerate (Conscious) Sedation - Professional and Facility

Policy CodePolicy C-25001

Change TypeAdded and revised

Effective DateFebruary 1, 2027

Next Review DateNot specified

Key ActionSubmit compliant CPT, HCPCS, and/or revenue codes supported by the medical record and office notes.

SourceLink

POLICY UPDATE CHANGES

The policy adds inpatient facility reimbursement rules that prohibit separate reimbursement of moderate sedation revenue codes 0371 and 0372 when billed with room and board charges.

The former professional-only moderate sedation policy was retired and combined with facility reimbursement requirements into this blended professional and facility policy.

4Applicable commercial market states

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CurrentWellpointPolicy C-25001

Moderate (Conscious) Sedation - Professional and Facility

Customize your policy alerts

Sign up for wellpoint Policy C-25001 alerts

Get alerted when Policy C-25001 changes without checking for updates manually.

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Policy Summary

PayerWellpoint

PolicyModerate (Conscious) Sedation - Professional and Facility

Policy CodePolicy C-25001

Change TypeAdded and revised

Effective DateFebruary 1, 2027

Next Review DateNot specified

Key ActionSubmit compliant CPT, HCPCS, and/or revenue codes supported by the medical record and office notes.

SourceLink

POLICY UPDATE CHANGES

The policy adds inpatient facility reimbursement rules that prohibit separate reimbursement of moderate sedation revenue codes 0371 and 0372 when billed with room and board charges.

The former professional-only moderate sedation policy was retired and combined with facility reimbursement requirements into this blended professional and facility policy.

4Applicable commercial market states

Separate reimbursement with same-provider reporting

2016 and olderBundling fee schedule

0371 and 0372Inpatient revenue codes not separately reimbursed

0710Outpatient recovery room code not separately reimbursed

Reimbursement Criteria

Professional provider reimbursement

Professional moderate sedation services are included in the reimbursement for professional providers and are not separately reimbursable unless provider, state, or federal contracts or requirements indicate otherwise.

Services included in professional reimbursement
- Assessment of the patient; assessment 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 is not included in intraservice time.
Applicable reimbursement and setting rules
- 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.
- For providers using fee schedules based on 2016 or older RVUs, moderate sedation is not eligible for separate reimbursement when the performing provider reports moderate sedation with a procedure listed in CPT Appendix G; the service is bundled with the Appendix G procedure.
- For 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, subject to the provider's contracted fee schedule and applicable contract or legal requirements.

Facility reimbursement restrictions

Facility reimbursement is subject to setting-specific claim, revenue-code, and facility-reimbursement restrictions.

Outpatient facility
- Recovery room services reported with revenue code 0710 are not separately reimbursable when billed with moderate sedation.
- Moderate sedation codes reported on a UB04 claim will be denied.
- Anesthesia revenue codes 037X must include a HCPCS/CPT code when billed with radiology or diagnostic revenue codes.
- The Maryland market does not apply to outpatient facility providers.
Inpatient facility

Coding and Fee Schedule Rules

CPT moderate sedation servicesCPTCovered

99151	Moderate sedation by the same physician or qualified healthcare professional as the diagnostic or therapeutic service; initial 15 minutes, patient younger than 5 years.
99153	Each additional 15 minutes of moderate sedation intraservice time by the same physician or qualified healthcare professional.
99155	Moderate sedation by a physician or qualified healthcare professional other than the provider performing the diagnostic or therapeutic service; initial 15 minutes.
99156	Moderate sedation by a different physician or qualified healthcare professional; initial 15 minutes, patient age 5 years or older.
99157	Each additional 15 minutes of moderate sedation intraservice time by a different physician or qualified healthcare professional.

HCPCS moderate sedation serviceHCPCSCovered

G0500

Moderate sedation service code subject to the policy's separate reimbursement and facility reimbursement restrictions.

CPT Appendix G proceduresCPTNot Covered

No codes listed

Outpatient facility revenue codesRevenueNot Covered

0710	Recovery room services; not separately reimbursed when billed with moderate sedation.
037X	Anesthesia revenue codes that require a HCPCS or CPT code when billed with radiology or diagnostic revenue codes.

Inpatient facility moderate sedation revenue codesRevenueNot Covered

0371	Moderate sedation revenue code not separately reimbursed with inpatient room and board charges.
0372	Moderate sedation revenue code not separately reimbursed with inpatient room and board charges.

RVU fee schedule rules

2016 and older RVUsModerate sedation is not eligible for separate reimbursement when the performing provider reports it with a procedure listed in CPT Appendix G.

2017 and later RVUsModerate sedation is eligible for separate reimbursement when the same provider reports both the procedure and the moderate sedation.

Fee schedule basisSeparate reimbursement depends on whether the provider's contracted fee schedule uses 2016-or-earlier or 2017-or-later RVUs.

Initial intraservice time

Initial time unit15 minutes of intraservice time.

Billing and Documentation Actions

Billing Rule

Professional Services Included in Moderate Sedation

Professional moderate sedation reimbursement includes the related professional services listed below and is not separately reimbursable unless provider, state, or federal contracts or requirements indicate otherwise.

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

Denial Risk

Key Terms

Independent trained observer

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

Monitoring roleThe observer assists in monitoring the patient's level of consciousness and physiological status.

Procedure contextThe observer is required for the moderate sedation services described with the applicable procedure codes.

Intraservice time

PurposeThe period used to determine the appropriate CPT code to report moderate sedation services.

BeginningIntraservice time starts with administration of the sedation agent or agents.

Ending

Policy Summary

PayerWellpoint

PolicyModerate (Conscious) Sedation - Professional and Facility

Policy CodePolicy C-25001

Change TypeAdded and revised

Effective DateFebruary 1, 2027

Next Review DateNot specified

Key ActionSubmit compliant CPT, HCPCS, and/or revenue codes supported by the medical record and office notes.

SourceLink

On This Page

Moderate sedation revenue codes 0371 and 0372 are not separately reimbursable when reported on an inpatient claim with room and board charges.

CPT 99151: Moderate sedation services provided by the same physician or other qualified healthcare professional performing the supported diagnostic or therapeutic service, requiring an independent trained observer; initial 15 minutes of intraservice time for a patient younger than 5 years. Eligible for separate reimbursement when reported with procedure codes reimbursed under 2017 or later RVUs in the provider's contracted fee schedule; not eligible for facility reimbursement.

CPT 99152: Moderate sedation services provided by the same physician or other qualified healthcare professional performing the supported diagnostic or therapeutic service, requiring an independent trained observer; initial 15 minutes of intraservice time for a patient age 5 years or older. Eligible for separate reimbursement when reported with procedure codes reimbursed under 2017 or later RVUs in the provider's contracted fee schedule; not eligible for facility reimbursement.

CPT 99153: Moderate sedation services provided by the same physician or other qualified healthcare professional performing the supported diagnostic or therapeutic service; each additional 15 minutes of intraservice time, reported in addition to the primary service. Eligible for separate reimbursement when reported with procedure codes reimbursed under 2017 or later RVUs in the provider's contracted fee schedule; not eligible for facility reimbursement.

CPT 99155: Moderate sedation services provided by a physician or other qualified healthcare professional other than the physician or other qualified healthcare professional performing the supported diagnostic or therapeutic service; initial 15 minutes of intraservice time for a patient younger than 5 years. Eligible for separate reimbursement when reported with procedure codes reimbursed under 2017 or later RVUs in the provider's contracted fee schedule; not eligible for facility reimbursement.

CPT 99156: Moderate sedation services provided by a physician or other qualified healthcare professional other than the physician or other qualified healthcare professional performing the supported diagnostic or therapeutic service; initial 15 minutes of intraservice time for a patient age 5 years or older. Eligible for separate reimbursement when reported with procedure codes reimbursed under 2017 or later RVUs in the provider's contracted fee schedule; not eligible for facility reimbursement.

CPT 99157: Moderate sedation services provided by a physician or other qualified healthcare professional other than the physician or other qualified healthcare professional performing the supported diagnostic or therapeutic service; each additional 15 minutes of intraservice time, reported in addition to the primary service. Eligible for separate reimbursement when reported with procedure codes reimbursed under 2017 or later RVUs in the provider's contracted fee schedule; not eligible for facility reimbursement.

CPT Appendix G codes include moderate sedation. These codes are automatically bundled with moderate sedation only when the fee schedule uses 2016 or older RVUs.

HCPCS G0500: Moderate sedation services provided by the same physician or other qualified healthcare professional performing the supported diagnostic or therapeutic service, requiring an independent trained observer to assist in monitoring the patient's level of consciousness and physiological status. No modifier override; not eligible for facility reimbursement.

Patient younger than 5 years

Code 99151 describes the initial 15 minutes when the same physician or qualified healthcare professional performs the associated diagnostic or therapeutic service.

Patient age 5 years or olderCode 99156 describes the initial 15 minutes when a different physician or qualified healthcare professional performs the associated service.

Additional intraservice time

Additional time unitEach additional 15 minutes of moderate sedation intraservice time.

Same providerCode 99153 reports each additional 15 minutes when the same physician or qualified healthcare professional performs the associated diagnostic or therapeutic service.

Different providerCode 99157 reports each additional 15 minutes when a different physician or qualified healthcare professional performs the associated service.

Sedation Provider Must Perform the Associated Procedure

In a non-facility setting, moderate sedation is not separately reimbursable when administered by a provider who is not performing the associated surgical, diagnostic, or therapeutic procedure.

Billing Rule

Older RVU Fee Schedules Bundle Moderate Sedation

When the contracted fee schedule uses RVUs from 2016 or earlier, do not separately report moderate sedation when the performing provider reports it with a procedure listed in CPT Appendix G.

Appendix G procedures include services that automatically bundle moderate sedation under 2016-and-earlier RVU-based fee schedules.

Billing Rule

Current RVU Fee Schedules May Allow Separate Reimbursement

When the contracted fee schedule uses RVUs from 2017 or later, separate reimbursement may be available when the same provider reports both the associated procedure and moderate sedation.

The associated procedure must reimburse based on 2017-or-later RVUs in the provider's contracted fee schedule.
The non-facility provider restriction still applies when a different provider performs the associated procedure.

Denial Risk

Outpatient Facility Billing Requirements

For outpatient facility claims, follow the reporting restrictions for recovery room, moderate sedation, and anesthesia revenue codes. Do not separately reimburse recovery room services billed with moderate sedation, and do not report moderate sedation codes on a UB-04.

Revenue code 0710: recovery room services are not separately reimbursed when billed with moderate sedation.
Moderate sedation codes reported on a UB-04 will be denied.
Anesthesia revenue codes 037X must include a HCPCS or CPT code when billed with radiology or diagnostic revenue codes.

Denial Risk

Inpatient Revenue Code Restriction

Do not separately reimburse moderate sedation revenue codes 0371 and 0372 when they are reported on an inpatient claim with room-and-board charges.

Revenue codes 0371 and 0372 are subject to this restriction when reported with inpatient room-and-board charges.

Billing Rule

Moderate Sedation Code Reimbursement Conditions

For the listed moderate sedation codes, separate reimbursement is eligible only when the associated procedure reimburses under 2017-or-later RVUs in the provider's contracted fee schedule. These codes are not eligible for facility reimbursement unless applicable contract, state, or federal requirements provide otherwise.

CPT 99151: same physician or other qualified professional performing the associated service; initial 15 minutes, patient younger than 5 years.
CPT 99152: same physician or other qualified professional performing the associated service; initial 15 minutes, patient age 5 years or older.
CPT 99153: same physician or other qualified professional performing the associated service; each additional 15 minutes.
CPT 99155: different physician or other qualified professional from the professional performing the associated service; initial 15 minutes, patient younger than 5 years.
CPT 99156: different physician or other qualified professional from the professional performing the associated service; initial 15 minutes, patient age 5 years or older.
CPT 99157: different physician or other qualified professional from the professional performing the associated service; each additional 15 minutes.
HCPCS G0500: moderate sedation service provided by the same physician or other qualified professional performing the associated service; no modifier override; not eligible for facility reimbursement.

Note

Maryland Outpatient Facility Exemption

Do not apply the outpatient facility portion of this policy to outpatient facility providers in Maryland.

Maryland outpatient facility providers are exempt from the outpatient facility requirements.

Documentation Required

Coding and Documentation Support

Submit compliant CPT, HCPCS, and/or revenue codes that accurately describe the services performed. The reported codes must be fully supported by the medical record and office notes; failure to follow coding and billing requirements may result in claim denial or payment recovery.

Use industry-standard, compliant codes on all claim submissions.
Services must also satisfy applicable authorization and medical-necessity requirements.
Noncompliant billing may result in rejection or denial of the claim, or recovery and recoupment of claim payment.

It continues with direct face-to-face attendance and ends when personal contact with the patient closes for the physician or qualified healthcare professional providing the sedation.

Conscious sedation

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

Drug-induced stateConscious sedation is a drug-induced depression of consciousness.

Patient responseThe patient responds purposefully to verbal commands.

Relative Value Units

DefinitionUnits of measurement for CMS resource, service, or procedure values relative to other services and procedures.

Measured valuesRelative Value Units measure the value of a CMS resource, service, or procedure.

Comparison basisThe values are measured relative to the value of all other services and procedures.