When my doctor personally performs moderate sedation of 15 minutes, does he/she need to document the time in the record?
Yes. Without documentation of the actual time, you can’t confirm that the doctor met the threshold of time needed to bill the code. That is, how do we know there was at least 8 minutes of time spent? According to the CPT rule pertaining to time, from the current CPT book, “A unit of time is attained when the mid-point is passed. For example, an hour is attained when 31 minutes have elapsed (more than midway between zero and sixty minutes).” When time is a descriptor in a CPT code, document the actual time.