IV Moderate Sedation - CDT Code Guide
Overview
CDT Code D9239 refers to intravenous moderate (conscious) sedation/analgesia for the first 15 minutes of a dental procedure. This code is used when a dentist or qualified anesthesia provider administers sedation to help manage pain and anxiety during dental treatments. The procedure involves the initiation of anesthesia and continuous monitoring of the patient to ensure safety and effectiveness. This type of sedation allows patients to remain conscious but relaxed, making it suitable for those who experience dental anxiety or are undergoing complex procedures. The anesthesia time begins when the provider starts the anesthesia protocol and ends when the patient can be safely monitored by trained personnel, allowing the provider to attend to other duties. The level of sedation is documented based on its effects on the central nervous system, not the administration method.
When to Use This Code
- During complex dental procedures requiring patient relaxation
- For patients with high anxiety levels about dental treatments
- When local anesthesia alone is insufficient for pain management
- In cases where patient cooperation is necessary but difficult to achieve
- For procedures expected to last longer than typical appointments
Documentation Requirements
- Start and end times of the anesthesia
- Detailed notes on the anesthesia protocol used
- Continuous monitoring records during the procedure
- Documentation of the patient's response to anesthesia
- Anesthesia provider's credentials and role
- Patient's consent for sedation
Billing Considerations
When billing for D9239, ensure that the procedure duration is accurately documented, as this code covers only the first 15 minutes of sedation. Subsequent time should be billed using additional codes. Be aware of any frequency limitations imposed by insurance providers, and use appropriate modifiers to indicate the level of sedation. Verify coverage with the patient's insurance, as some plans may have specific requirements or restrictions for sedation services.
Related CDT Codes
Frequently Asked Questions
Moderate sedation allows the patient to remain conscious and responsive, whereas deep sedation may render the patient unconscious and less responsive to stimuli.
Need help with dental coding?
Our AI-powered assistant can answer your CDT code questions instantly.