My doctor documents moderate sedation time as “approximately xx minutes.” Is this appropriate documentation of time?


No, this is not appropriate. Because moderate sedation is a time-based code, the exact time must be documented. This should be in the medical record and the doctor should be able to give either the start and stop times (of face-to-face service) or the total exact time. If the doctor reports an approximate time, send it back for correction and amendment.


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