Conscious Sedation

Reimbursement Policy:
Conscious Sedation

Effective Date:
June 1, 2006

Last Revised Date:
June 13, 2017

Purpose:
To provide guidelines for the reimbursement of conscious sedation

Scope:
All products are included, except

• Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap)
• COB

All Insured and Administrative Services Only (ASO) accounts are included.

Policy:
Procedure codes 99151, 99152, 99155, 99156, and G0500 are classified as medical codes. Only one (1) unit is considered for reimbursement per date of service.

Procedure codes 99153 and 99157, also classified as medical codes, may be used to report additional units. Multiple units of these codes are considered for reimbursement.

The CPT codes/nomenclature used in this policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the policy will continue to be in force, albeit applied to the new or amended coding so issued until this policy is revised to reflect new/amended coding.

Procedure:
Horizon BCBSNJ shall reimburse for conscious sedation at the applicable Horizon BCBSNJ fee schedule.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

In instances where the provider is not participating, member liability shall be up to the provider’s charge.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

• Group or Individual benefit
• Provider Participation Agreement
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
• Mandated or legislative required criteria will always supersede.

History:
04/11/2016: Policy approved
06/13/2017: Replaced deleted codes 99143, 99144, 99145, 99148, 99149, 99150 with revised codes

Policy003_v2.0_06132017