Minimal sedation with E/M service

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Joined: Tue Mar 27, 2018 7:25 pm

Fri Sep 28, 2018 12:20 pm

I have seen some information that minimal sedation is included in the E/M service and cannot be billed separate if done in the same service. Can this be confirmed?

If an E/M is documented with a time statement and counseling and coordination of care is done in addition to the minimal sedation does there need to be a statement that the time spent in counseling/coordination of care was separate of procedures? Does the time for the sedation need to be documented in the E/M?
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Thu Oct 04, 2018 1:59 pm

Minimal sedation is included in the E/M services as it is done using medication, that does not require extensive independent monitoring, or injection services. Since it is not a separately billable service, and does not require independent monitoring, it does not have to be excluded when documentation supports otherwise billing based on time. HOWEVER, whatever procedure was performed, that required the sedation, does need to be specifically excluded from the documentation of time.

Each Medicare contractor has their own reference on this, so make sure to query your MAC for the reference.

Your question has been answered by Omega Renne, CPC, CPCO, CPMA, CEMC, CIMC
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