Personal history of failed moderate sedation

This code indicates that a patient has a documented history of experiencing an unsuccessful attempt at moderate sedation. This means the intended level of sedation was not achieved, or the patient reacted adversely, preventing the successful completion of the procedure under moderate sedation in the past.

This code is appropriate when a patient's medical record explicitly states a prior failure of moderate sedation, regardless of the reason. It is often used to inform future anesthetic planning or when a patient presents for a procedure where moderate sedation might typically be considered but was previously ineffective or problematic.

• Do not use this code for a failed moderate sedation event occurring during the current encounter; refer to the Excludes2 note.
• Ensure documentation clearly specifies "moderate sedation" and not another level of sedation (e.g., conscious sedation, deep sedation).
• This code is typically a secondary diagnosis, providing historical context for the patient's care.