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

February 2017

Moderate Sedation Reimbursement for GI Endoscopic Procedures


As we reported in the December issue, as of April 1, 2017, Harvard Pilgrim will provide separate reimbursement for the following newly released codes for moderate sedation when it is provided by the same physician performing the procedure that the sedation supports: 99151, 99152, 99153, and G0500.

We would like to provide further clarification that Harvard Pilgrim will not reimburse code 99152 for moderate sedation in conjunction with a gastrointestinal endoscopic procedure; HCPCS code 99152 is intended for use only for services other than gastrointestinal procedures (initial 15 minutes; patients age 5 or older).

For gastrointestinal procedures, you must use one of these codes depending on the age of the patient: 

  • G0500 — patient age 5 or older; initial 15 minutes of moderate sedation for gastrointestinal procedures only
  • 99151 — patient younger than age 5; initial 15 minutes moderate sedation for gastrointestinal or other procedures

When submitting claims for reimbursement for gastrointestinal endoscopic services, pair the applicable moderate sedation code with the CPT code for the primary service (codes 43200-45398, G0105, or G0121).

Codes 99152, G0500, and 99151 are all used to bill for the initial 15 minutes of moderate sedation. For moderate sedation beyond the initial 15 minutes, code 99153 should be used regardless of type of procedure or the age of the patient.

For more information, please refer to the updated Gastroenterology Payment Policy and Anesthesia Payment Policy.

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PUBLICATION INFORMATION

Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Vice President, Network Services

Annmarie Dadoly,
Editor

Joseph O'Riordan,
Writer

Kristin Edmonston,
Production Coordinator