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

Background

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.

CLINICAL PAYMENT, CODING AND POLICY CHANGES

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.