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Moderate Sedation and Independent-trained Observer

January 25, 2017
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Question:

In the AMA CPT 2017 Professional edition, on page 676-677, they outline an independent-trained observer (qualified to monitor the patient during the procedure, who has no other duties during the procedure). Then on page 677 under the intraservice work, they note intraservice time is used to determine the appropriate CPT to use during the procedure. Then if you go to the bullet point, they note, “Requires continuous face-to-face attendance of the physician or other qualified health care professional.”

The physician who performs the procedure and uses an independent-trained observer to administer the moderate sedation and monitor the vital signs —  in this Intraservice Work — in bullet point 5 —  the face-to-face attendance of the physician or other qualified health care professional . . . so the other qualified and health care professional and the independent trained observer are NOT the SAME thing?

Answer:

There isn’t any specific direction or explanation for these guidelines, however, we would agree with your interpretation.

The independent-trained observer (as noted on page 676 of the 2017 CPT manual Professional edition) is not the same person as the physician or other qualified health care professional as noted in the fourth bullet on page 677 under Intraservice Work which states, “Requires continuous face-to-face attendance of the physician or other qualified health care professional.” These are two different people.

Intraservice Work seems to require the continuous face-to-face time with the physician or other qualified healthcare professional. This does not include an independent-trained observer who has no other duties than to monitor the patient during the procedure — this is a separate role

So, you must have the physician or other qualified healthcare professional with face-to-face time in order to count the time as Intraservice Work. If the physician has chosen to use someone else to function as an independent-trained observer with no other duties, this is acceptable, but that person’s time cannot be included as Intraservice Work. In other words, that independent person’s time does not count towards Intraservice Work. Intraservice Work requires the involvement (face-to-face time) of the physician or other qualified healthcare professional, and no one else.

2 Comments

    DeAnna Fling says:

    Looking for a definition of an “independent trained observer.” Who qualifies for this role and what are the job responsibilities.

      Jodi Stewart says:

      Thank you for your question related to a definition for an “independent trained observer” as it relates to CPT® guidelines.

      CPT® defines an independent trained observer as, “….an individual who is qualified to monitor the patient during the procedure, who has no other duties (eg, assisting at surgery) during the procedure.” CPT® guidelines do not address specific educational requirements or job responsibilities for the independent trained observer.

      Individual state licensing requirements will determine who is legally authorized and qualified to provide such services. Your credentialing office will most likely be familiar with the education and/or certifications required for an individual who is providing such monitoring. Further, your medical staff bylaws and/or individual departmental policy/procedures may address what responsibilities are expected of someone monitoring the patient in this scenario as well as who is qualified to perform these tasks within your facility based on your state’s criteria.

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