Friday, 31 May 2019

CPT 00170, 00190, 41899, D9220 - D9248 - Dental Anesthesia procedure

CPT Codes Description Modifiers Maximum Units

00170 Anesthesia for intraoral procedures, including biopsy; not otherwise specified  U1 7Unit

00190 Anesthesia for procedures on facial bones or skull; not otherwise specified

41899 Other Procedures on the Dentoalveolar Structures (facility fees)

D9220 Deep sedation/general anesthesia, first 30 minutes

D9221 Deep sedation/general anesthesia, each additional 15 minutes

D9241 Intravenous conscious sedation/analgesia, first 30 minutes

D9242 Intravenous conscious sedation/analgesia, each additional 15 minutes

D9248 Non-intravenous conscious sedation


Sedation and anesthesia for dental procedures performed on patients in nontraditional settings, such as acute inpatient facility or ambulatory surgery center, have increased over the past several years. Providers must be qualified and appropriately trained individuals in accordance with state regulations and professional society guidelines.

All locations that administer general anesthesia must be equipped with anesthesia emergency drugs, appropriate resuscitation equipment, and properly trained staff to skillfully respond to anesthetic emergencies. Locations covered under this policy are acute care inpatient facilities and ambulatory surgery centers.

General anesthesia allows for the safe and humane provision of dental diagnostic and surgically invasive procedures. General anesthesia is only necessary for a small subset of members but is an effective, efficacious, and safe way to provide necessary treatment. Those included in this subset are individuals who may be cognitively immature, highly anxious or fearful, have special needs, or medically compromised and unable to receive treatment in a traditional office setting.

Dental Anesthesia

Withholding of general anesthesia can result in less access to quality oral health care and long-term consequences. Less effective management of these members may increase avoidance behaviors of oral health professionals in the future and increase care being sought in the emergency department. Improved diagnostic yield and greater quality of procedures improves the cost-effectiveness of general anesthesia over local anesthesia in some individuals.

Local Anesthesia or conscious sedation (oral/inhalation) failed (V.A.)

Documentation provided must support/justify the need for the consideration of using IV Sedation or GA.


Dental services requiring general anesthesia must be coded as follows:

• Procedure code 00170 must be billed with modifier U3 and is for the anesthesiologist or certified registered nurse anesthetist (CRNA) to use on the claim form. Procedure code 00170 with modifier U3 will require prior authorization for all patients under the age of 21.

• Procedure code 41899 is for the facility to use on the claim form. Procedure code 41899 will require an authorization for all patients, regardless of age or modifier.

• An appropriate diagnosis code must be used on the claim form.

• The examining physician, anesthesiologist, hospital, ASC, or HASC must submit claims separately for the medical and facility components of their services.

Claims submitted for dental services requiring dental anesthesia with CPT code 00170, modifier U3, and a patient under the age of 21 will pend to our Claims Team who will review for a prior authorization. Claims with CPT code 00170, modifier U3, and a patient under the age of 21 that do not have a prior authorization will be denied. Claims submitted for dental services requiring dental anesthesia with CPT code 41899 will pend to our Claims Team who will review for a prior authorization. Claims with CPT code 41899 that do not have a prior authorization will be denied.

Dental Therapy under General Anesthesia

Modifier U3 will no longer be used with procedure code 00170 when billing for the appropriate reimbursement of dental general anesthesia. The new modifier to be used with procedure code 00170 for dental general anesthesia is EP.

For clients who are six years of age or younger, the following will change:

• All Level 4 sedation services provided by a dentist (procedure code D9223) must be prior authorized.

• Any anesthesia services provided by an anesthesiologist (M.D./D.O.) or certified registered nurse anesthetist (CRNA) to be provided in conjunction with dental therapeutic services (procedure code 00170 with EP modifier) must be prior authorized.

• The dentist performing the therapeutic dental procedure is responsible for obtaining prior authorization for both services from TMHP and is responsible for providing the anesthesia prior authorization information to the anesthesiology provider.

• The current process of scoring 22 points on the Criteria for Dental Therapy Under General Anesthesia form does not guarantee authorization or reimbursement for clients who are six years of age and younger.

Procedure Code Updates

Procedure code 00170 with modifier EP and procedure code D9223 will be limited to once per six calendar months, any provider.

The following payable provider types will be added for procedure code 00170 with modifier EP, and procedure code D9223:

Procedure Code Place of Service Provider Types

00170 with modifier EP Office Physician providers

D9223 Inpatient hospital, outpatient hospital dentist, orthodontist, and oral maxillofacial surgeon providers

Procedure Code Limitations

Procedure codes D1110, D1120, D1206, D1208, D1351, and D1352 will be denied when submitted for the same date of service as any D4000 series periodontal procedure code, any provider.
Periodontal scaling and root planing (procedure codes D4341 and D4342) will be denied when submitted for the same date of service as other D4000 series codes, except D4341 and D4342, any provider.

Full mouth debridement (procedure code D4355) will be denied when submitted for the same date of service as the following procedure codes, any provider:

Procedure Codes

D4210 D4211 D4230 D4231 D4240 D4241 D4245
D4249 D4260 D4261 D4266 D4267 D4270 D4273
D4274 D4275 D4276 D4277 D4278 D4283 D4285
D4320 D4321 D4381 D4910 D4920 D4999

Dental hospital calls (procedure code D9420) are currently limited to twice per rolling year, per client, any provider. Procedure code D9248 will be denied when submitted for the same date of service as procedure code D9420, any provider.

Anesthesia procedure code D9243 will be limited to one and one-half hours per day. Oral maxillofacial surgeon providers will be added as a payable provider type for procedure code D9243 when services are provided in the outpatient hospital setting.

Procedure code D9230 currently denies when submitted for the same date of service as procedure code D9248, same provider.

Documentation and billing

The anesthesia record must clearly define and document that portion of time that anesthesia is rendered by the provider of anesthesia services. Documentation must include an explanation of the service performed, the duration of the service and the length of time the rendering physician, resident, CRNA or anesthesia assistant was involved with the case. Submit a copy of the anesthesia record and the supporting documentation when you file a claim on the CMS-1500 form for anesthesia services.
BCBSM requires time to be reported in actual minutes of anesthesia care for anesthesia claims. Our claim system will round up the minutes to 15-minute time units. Report all appropriate modifiers to ensure accurate payment. If the same provider performs both dental surgery and anesthesia, the anesthesia is included in the billed dental surgical procedure.

General anesthesia and intravenous sedation are billable under the medical-surgical program in conjunction with procedures billed under the dental program. The dental procedures must meet medical criteria and must be performed in a hospital by a health care provider other than the surgeon. Dental procedures such as preventive services, restorations, endodontics, periodontics, extractions, etc., are not covered under the medical-surgical program and should be billed to the patient’s dental plan

Medical necessity criteria

• There are no medical contraindications to treatment.
• Documentation that more conservative treatment has been attempted and has not been successful must be provided.
• Totally edentulous mandible must have less than 20 mm in radiographic height from the inferior border to the crest of the ridge in the mandibular symphysis region.
• Documentation of the functional problem(s) associated with the mandibular deformity must be provided.

Local Anesthesia or conscious sedation (oral/inhalation) not feasible (V.B.)

Effective communicative techniques and the immobilization failed or is /was not feasible.
Requires extensive/complex dental treatment.
Patient has acute situational anxiety due to immature cognitive functioning .
Patient is uncooperative due to certain physical or mental compromising conditions.
Local anesthesia is/will be ineffective because of acute infection, anatomic variation, or allergy.
Local anesthesia is/will be ineffective or compromised because of oral-facial and/or dental trauma.
Dental Anesthesia Performed In Dental Offices
Effective July 1, 2018, a number of dental providers have opted to obtain a permit from the NH Board of Dental Examiners for providing general anesthesia and moderate sedation in their offices. These providers have been authorized by DHHS to allow either a dental anesthetist or a CRNA to provide such services to NHHF members. The service must be prior authorized by the Dental department at DHHS to be reimbursed by NHHF. The anesthesia charges must be billed separately on a CMS 1500 form using the specific coding in the table below, Dental Anesthesia Performed in Dental Offices.

Sunday, 17 December 2017

Covered Service

Health benefits which are allowed per a contract with a health insurance company or a health benefit allowed by Medicare, Medicaid, Tricare or Workers Compensation.

CPT – Current Procedural Terminology: 
CPT is a list of procedure codes owned, copyrighted and developed by the American Medical Association. A procedure is something that the doctor does to a patient during a visit. For example, if you cut your finger and the doctor repairs the cut, there is a procedure code to put on the claim form. The code is recognized by coders, and insurance company claims software. Let’s look at the cut on the  finger. To convert the repair to a CPT code, you need to know the length of the wound, in centimeters so you can select the correct CPT code. For the purpose of this example. You have a 1cm simple cut on your index finger. The repair of this cut would be 12001. Every procedure performed MUST be supported by a correct diagnosis code or ICD-9 code. The diagnosis or ICD-9 code for an unspecified wound of the finger would be 883.0. Now, if you saw ICD-9 code 042 used with CPT code 12001, you would be confused. That would be like saying the doctor sutured the patient’s finger cut because the patient had AIDS. Therefore it doesn’t make sense to suture a wound if there is no open wound diagnosis.

A deductible is a contractual amount that the patient is required to pay as an out of pocket expense before the insurance company pays any claim sent to them. The amount of deductible varies per patient and per insurance policy. Commercial insurance and Medicare deductibles start in January of each year. Tricare deductibles start in October each year. A patient may have a $1,000 deductible. The patient is seen by the doctor on January 5th. The claim is for $250.00. The insurance company allows $100 for the benefit or covered service. The patient hasn’t met their deducible yet. The $100 is applied to the deductible. Now the patient has a $900 deductible to meet before the claim is paid by the insurance company. The patient comes in each month for the next 9 months. The claim is sent in September. The $100 is applied to the remaining deductible. If the patient comes in the next month (October), the deducible has been satisfied, so now a check will be sent by the insurance company. Whether the patient actually pays the deductible is between the provider and patient. The insurance company doesn’t care if the patient doesn’t actually pay the deductible. All this means is that with a $1,000 deductible, with $100 allowed for the visit it will take 10 visits before the insurance company will release any money to pay the patient’s claim. Medicare does care if the provider collects the deductible from the patient.

A Spouse and/or an unmarried child (whether natural, adopted or step) of an insured person. When looking at the insurance card (other than Medicare) you may see the policy number and at the end, you may see 01, 02, 03, 04 or another 2 digit number. These numbers have meaning, but could vary per insurance company.

00: Insured or member (Some insurance companies may have 01 as the insured)

Monday, 11 December 2017


Co-payment or co-pay is a predetermined (flat) fee, based on a contract between an employer or patient and an insurance company A co-payment that a patient pays for health care services is in addition as an out of pocket expense to what the insurance company covers for the service provided. A co-pay is separate from a deductible and co-insurance. For example, a patient may have coverage through Blue Cross and Blue Shield. The policy may require the patient to pay a $10 copayment for each office visit, regardless of the type or level of services provided during the visit. A patient coming in for daily blod pressure checks could be required to pay the co-pay for each BP check visit. Co-payments are not usually specified by percentages. Co-pays are usually paid at the time of service. Some providers will bill the patient for the co-pays. A huge question that is always asked is, “Can we write off the co-pay owed by the patient. This question has NO easy answer. Again, the co-pay is a contractual amount that the patient is required to pay. Writing off co-pays on a routine basis could be determined by a Government Inspector as an incentive to have the paient make referrals to the provider. The insurance company could take the position that writing off a co-pay is a contract violation. The key word with doing a write off is routine. Each write off should be on a case by case basis. The patient may be financially unable to pay the co-pay. If, so then it would be permissible to write off the co-pays. There are at least three (3) acceptable means of writing off what a patient may owe. (1) The provider has made every effort to make collection on what is owed and this includes a debt collection agency. (2) if it would cost more to collect than what is owed. For example, the patient owes $1.95. It costs $10 in administrative expenses to bill a patient. Therefore the cost to collect is more than what is owed. The $1,85 could ne adjusted off as a small balance adjustment, and (3) The patient is financially unable to pay. The patient must prove they are financially unable to pay. This can be in the form of wage statements, bank statement, tax statement and lists of monthly bills such as electricity, food, and other bills.

COBRA Consolidated Omnibus Budget Reconciliation Act.  
This is a Federal Law that allows a worker to continue to purchase employer paid health insurance for up to 18 months if you lose your job or your coverage is otherwise terminated. For example, your employer provides you with health insurance through United Healthcare as a benefit of employment. The employer is going out of business or you leave for another job. Under COBRA, you can continue to keep your United Healthcare coverage when you leave your employer. 

The catch to this is that YOU must continue to pay the premiums that your employer paid. Some people decline this because they cant afford the premiums. If the patient kept the COBRA coverage make sure you verify that the coverage is still in effect at the time of service. The patient may present the United healthcare insurance card but you find out that the patient did not pay the premiums, so the coverage was terminated. 

Tuesday, 5 December 2017

CMS – Centers for Medicare and Medicaid Services

CMS is a Federal Agency responsible for overseeing and regulating Medicare and Medicaid. CMS come under the jurisdiction of the Department of Health and Human Services. CMS is also the agency responsible for monitoring an approving the code sets (CPT and ICD-9) under HIPAA. Medicare HMOs come under the jurisdiction of the area CMS offices. Medicaid HMOs come under the jurisdiction of a State Medicaid agency. CMS used to be called HCFA, the Health Care Financing Administration.

CMS 1500: 

The CMS 1500 is the current HIPAA approved standard paper claim form submitted to insurance companies to have the outpatient health benefit or the contracted provider visit paid. The CMS 1500 form is designed by the National Uniform Claim Commission. Most insurance companies desire to have the CMS 1500 form sent to them in an electronic format. The fields or blocks on the form are the same regardless if on paper or done electronically. The CMS 1500 claim form instructions can be found here: 


The process of converting a medical procedure, a surgical procedure, a hospital inpatient stay or a doctor visit to a CPT code. The medical diagnosis is converted to an ICD-9 code. Some supplies are converted to HCPCS Codes. The purpose of coding is to document the reason for the visit or service and what was done during that visit so that the insurance company’s computers can quickly recognize the coded numbers and process the claim for payment.

Thursday, 30 November 2017


This term can have many meanings. Capitation represents a set dollar limit that is paid to a provider by an insurance company for treating their members. This set dollar limit can be based on a monthly dollar amount, a per patient dollar amount or a per claim dollar amount. The insurance company can say that they will pay the provider $3,000 per month. This can equate to $10 per day. If the provider treats 10 patients per day, the provider makes $1.00 per patient per visit. The provider may be required to submit a claim but there won’t be any additional payment on the claim. The payment per claim could be $90 per claim. This means you send a claim and each claim should be paid $90 regardless of how many codes are submitted. With a per claim payment, the biller must keep a close eye on the claim payments, this is because some insurance companies will pay the claim less than the amount agreed upon in the contract. This will require you to appeal the incorrect payment and continue until it is paid correctly. Before agreeing to a capitated amount, the provider should make sure the capitated amount is fair and reasonable. This is something that will be discussed more in another document on Insurance Contracts.


This is nothing more than a shorter name for an insurance company. For example. First Coast is the local carrier for Medicare Part B for Florida and Georgia. Anoher example would be, $75 is the usual and customary reimbursement amount for the carriers in our geographical area. In simplistic terms, all the insurance companies in our area pay $75 for a claim.

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