Conscious Sedation Billing Form

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Doctor Name ______________________________________
Pt Name __________________________________________
(Or please attach ER sheet or Pt label)
Date of Service ____________________________________
Conscious Sedation Billing
1172 / 01Z – Conscious sedation. NOTE – this fee is not billable with any reductions by the same physician
Start time _________ end time __________
______ not in OR, please confirm
_______ # units (per 15 minutes or any portion)
______________________ Fee code for any non-orthopedic procedure you are also billing (orthopedic
procedures should be billed under “with GA” code and no 1172 by same physician). This requires a
note explaining the medical necessity of having why it was necessary to have one physician do both the
sedation and the procedure.
( ) only physician available or ________________________________
___________________________________________________________________________________
Also - If the procedure noted generally includes anesthesia (e.g 13611/12, 13620/21/22. 6075/76/77 etc)
then a note explaining the need for the additional anesthesia is required. Please provide an applicable
note:
_________________________________________________________________________________
_________________________________________________________________________________
__________________________________________________________________________________________
13052 / 01Z - A pre-anesthetic evaluation may be payable, but only to the doctor who bills an 1172. The 13052
must precede the 1172 and not be in the OR and times are required to establish non-concurrent services so a
note is required providing times for both services. Please indicate:
______ 13052 / 01Z – Pre-anesthetic evaluation for GPs
Start time __________ end time ____________
______ Not in OR, please confirm
______ Alternate / additional visit code (please specify)
Start time __________ end time ____________
(if billing a visit in addition to a 13052 times must be significantly different and included in a note)
__________________________________________________________________________________________
Intubation Billing Template for GPs
1091– Intubation. Not billable if you are the MRP unless this is the only code you are billing.
If asked to do the intubation after a transfer of care when you were no longer MRP then a note is
required. Transfer of MRP care to Dr _________________ at _________hours Then asked to do
intubation at ________________
Updated June 2016 Reprinted with permission of Valley Medcom Billing Inc
604-888-8826

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