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Question:
My doctor documents moderate sedation time as “approximately xx minutes.” Is this appropriate documentation of time?
Answer:
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.
CPT® copyright 2021 American Medical Association (AMA). All rights reserved.
Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
CPT is a registered trademark of the American Medical Association.
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