Coverage Policies

Important! Please note:

Current policies effective through April 30, 2024.

Use the index below to search for coverage information on specific medical conditions.

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Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

QualChoice follows care guidelines published by MCG Health.

Clinical Practice Guidelines for Providers (PDF)

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
Effective Date: 01/15/2007 Title: Conscious Sedation
Revision Date: 07/01/2017 Document: BI176:00
CPT Code(s): 99143-99145, 99151-99153
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above Revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

For minor procedures, moderate sedation may be provided by the physician performing the procedure. When the procedure is covered, QualChoice will cover the sedation services provided. The provider is responsible for appropriate billing.
Medical Statement

1)    The CPT book is clear that when regional or systemic medication (conscious sedation) is administered by the surgeon (the physician performing the procedure), the anesthesia codes (00100-01999) are not to be used. Such claims will be denied.

2)    QualChoice will also not pay for modifier -47. This is a modifier intended to indicate that the anesthetic for the procedure was provided by the surgeon. For instances when conscious sedation is used, see rule 3 below. For instances when a regional block is used, the specific code for the regional block should be used.

3)    The CPT book indicates that systemic medication (conscious sedation) provided by the surgeon is to be coded using 99151-99153. QualChoice will recognize and reimburse these codes.

4)    The use of inhaled nitrous oxide is considered analgesia/anxiolysis, not moderate sedation.  Such use is considered part of the procedure and is not separately billable.

5)    99155 – 99157 (mod sedation services by someone other than the provider performing the procedure for which sedation is required) are not covered.

 

Codes Used In This BI:

99143           Mod cs by same phys <5 yrs. (code deleted 1/1/17)

99144           Mod cs by same phys 5 yrs. + (code deleted 1/1/17)

99145           Mod cs by same phys add-on (code deleted 1/1/17)

99151           Mod sedation svcs by same phys perf svcs, req an indep trained observer to assist monitoring consciousness/status; initial 15 mn, < 5 yrs (new code 1/1/17)

99152           Mod sedation svcs by same phys perf svcs, req an indep trained observer to assist monitoring consciousness/status; initial 15 mn, 5 yrs + (new code 1/1/17)

99153           Mod sedation svcs by same phys perf svcs, req an indep trained observer to assist monitoring consciousness/status; ea addtl 15 mn (new code 1/1/17)

99155           Mod sedation svcs by physician or other qualified healthcare professional other than the physician performing the procedure for which sedation is needed; initial 15 mn, < 5 yrs (new code 1/1/17)

99156           Mod sedation svcs by physician or other qualified healthcare professional other than the physician performing the procedure for which sedation is needed; initial 15 mn, 5 yrs + (new code 1/1/17)

99157           Mod sedation svcs by physician or other qualified healthcare professional other than the physician performing the procedure for which sedation is needed; ea addtl 15 mn (new code 1/1/17)
Reference

Addendum:

1.     Effective 01/01/2017: 2017 Coding Updates to Codes Used in This BI and Medical Policy Statement sections: Removed CPT deleted codes 99143 – 99145 and replaced with new codes 99151 – 99153.

2.     Effective 07/01/2017: New (excluded) codes (99155-99157) added.

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.
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