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Moderate Sedation - definition of "Independent trained observer"

Date: Jan 7, 2022

Question:

Our hospital interventional radiology and interventional cardiology departments have a question about the definition of an "independent trained observer" when it comes to charging for codes 99151, 99152, and 99153 for moderate sedation.

What documentation is required by the facility and/or by the physician to support the presence of an independent trained observer? Can moderate sedation be charged if the RN providing the sedation and monitoring is also the circulator? Does the independent trained observer need to remain with the patient for the entire procedure, or can they perform other tasks within the room or nearby? Does this independent trained observer need to be the RN who administered the meds, or can it be a monitor tech or other staff member? We are trying to determine when it is and when it is not appropriate to charge for moderate sedation based on the staffing for the procedure and who is providing the sedation and monitoring.

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