Patient Case: Stenting in STEMI With Moderate Sedation

A 65-year old patient presents with substernal chest pain, anterior ST-segment elevation myocardial infarction (STEMI) and is taken emergently to the cath lab for PCI. The interventional cardiologist assesses the level of consciousness and need for airway protection and then orders moderate sedation prior to procedure: 1mg of Versed and 25mcg of Fentanyl. The patient undergoes stenting of the left anterior descending artery with a drug eluting stent, with TIMI 3 flow in the culprit vessel at the end of the procedure. The duration of the procedure was 75 minutes. Given recent changes in moderate sedation coding, how should the physician code for this procedure?

Starting in 2017, the Centers for Medicare and Medicaid Services (CMS) have removed the work value of moderate sedation from all "Appendix G" procedures that previously included moderate sedation as an inherent part of the procedure. A 0.25 work RVU reduction from the current values will take place. Instead, new patient-age dependent moderate sedation base codes (for initial 15 minutes)* and add-on codes (for each additional 15 minutes)** were created.

Therefore, code 92941*** should be used for STEMI PCI, 99152* for moderate sedation (initial 15 minutes), and 99153** x4 times for moderate sedation, each additional 15 minutes. The code 99152 is valued as 0.35 total in-facility RVUs. CMS considers 99153 a "technical code"; therefore, 99153 is not payable in the hospital for physicians (payment is for non-facility only). Currently, the ACC is working with CMS to get clearer guidance on billing the CPT® code 99153 in the facility setting, but for now we would recommend still coding the 99153 until better guidance is provided.

*99152 - Moderate sedation services provided by the same physician or other qualified health care 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 intra-service time, patient age 5 years or older.

**99153 - incrementally increased for each additional 15 minutes.

***92941 - Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel.

This article was authored by Dmitriy N. Feldman, MD, FACC, editor of the Early Career Newsletter and member of ACC's Coding Task Force Committee, and Debra Mariani, coding and physician reimbursement staff at ACC.

Email Debra Mariani, coding and physician reimbursement staff at ACC at dmariani@acc.org, for more information or questions on coding or billing.