Moderate Sedation Documentation

Question:

Is use of the nurse flow sheet when billing for moderate sedation with our pain injection procedures allowed?

Answer:

Per CPT coding guidelines, when billing for moderate sedation an independent trained observer is required.  An independent trained observer is an individual who is qualified to monitor the patient during the procedure, who has no other duties (e.g. assisting at surgery) during the procedure. 

Moderate sedation must be documented in the body of the procedure report; a separate flow sheet is not sufficient for the surgeon documentation.  Document “ I personally supervised Mary Brown RN providing 45 minutes of moderate sedation with XX mg Versed and XX mg Fentanyl”. 

*This response is based on the best information available as of 5/23/24.