Moderate Sedation - Enteral - CDT Code Guide
Overview
CDT code D9245 refers to the administration of moderate sedation via the enteral route. This procedure involves using oral or rectal medications to achieve a state of moderate sedation, where the patient is relaxed and comfortable but still able to respond to verbal commands. This type of sedation is commonly used in dental procedures that require the patient to be calm and still, yet conscious enough to cooperate with the dentist. Typical scenarios include lengthy procedures, patients with dental anxiety, or those with a strong gag reflex. Clinically, moderate sedation is a step above minimal sedation and is used when a deeper level of sedation is necessary but general anesthesia is not required.
When to Use This Code
- Patients with significant dental anxiety undergoing lengthy procedures
- Procedures requiring the patient to remain still for an extended period
- Patients with a strong gag reflex that interferes with dental treatment
- Complex restorative or surgical dental procedures
- Patients who have difficulty achieving adequate local anesthesia alone
Documentation Requirements
- Detailed patient medical history and pre-sedation assessment
- Informed consent specific to moderate sedation
- Documentation of sedation agents and dosages used
- Monitoring records of vital signs during the procedure
- Post-sedation recovery and discharge notes
Billing Considerations
When billing for D9245, ensure that the procedure is medically necessary and documented thoroughly. Check for any frequency limitations imposed by insurance providers. Common modifiers include those for additional complexity or extended time. It's important to verify coverage with the patient's insurance, as some plans may have specific guidelines for sedation services.
Related CDT Codes
Frequently Asked Questions
Moderate sedation allows the patient to remain conscious and responsive, while general anesthesia renders the patient completely unconscious.
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