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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

December 2016

Updates to Reimbursement for Moderate Sedation Services


Effective January 1, 2017 for our Medicare Advantage StrideSM (HMO) products and April 1, 2017 for our commercial products, Harvard Pilgrim will provide separate reimbursement for certain moderate sedation services provided by the same physician performing the procedure that the sedation supports. These services are not currently reimbursed separately; payment for these services is included in the payment for the procedure itself. However, on or after April 1, 2017 — when Harvard Pilgrim’s fee schedules are updated — for our commercial plans and on or after January 1, 2017 for our Medicare Advantage plans, payment for the following codes will not be included in the payment for the associated procedure, and will be reimbursed separately:

  • 99151 – 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 intraservice time, patient younger than 5 years of age
  • 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 intraservice time, patient age 5 years or older
  • 99153 – 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; each additional 15 minutes intraservice time (List separately in addition to code for primary service)
  • G0500 – Moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service (excluding biliary procedures) that 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 (additional time may be reported with 99153, as appropriate)

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