Organizations ask CMS to identify ‘coding solution’ for dental surgeries

Baltimore — The ADA, American Academy of Pediatric Dentistry and American Association of Oral and Maxillofacial Surgeons are asking the Centers for Medicare & Medicaid Services to improve patient access to dental procedures in hospitals and surgery centers.

In comments filed Sept. 17 with CMS, ADA President Daniel J. Klemmedson, D.D.S., M.D., AAPD President K. Jean Beauchamp, D.D.S., and AAOMS President B.D. Tiner, D.D.S., M.D., are requesting that the agency work with the organizations to identify a coding solution to current hospital and ambulatory surgical center billing limitations, which have significantly restricted Medicare and Medicaid patient access to covered dental outpatient surgeries.

The three organizations shared the following in response to the hospital outpatient prospective payment system proposed rule for calendar year 2022 and future years:

Oral health disparities and access to dental surgeries. Despite advances in preventive care and an overall reduction in untreated tooth decay, “significant oral health disparities exist, including racial and ethnic disparities and geographic disparities.” ADA, AAPD and AAOMS noted that Medicare and Medicaid beneficiaries with special needs and disabilities, and the frail elderly “disproportionately suffer” from dental caries and if those patients aren’t treated through dental surgical intervention, this disease can result in emergency department visits and life-threatening infection and hospital admission. “Given the time involved for restorative dental surgical procedures, the often-complex equipment and anesthesia required, and the complexity of the services required for high-risk patients, many times dentists need to provide these services in a facility operating room to ensure safe, quality care,” they wrote.

Medicare coding limitations. Dental rehabilitation surgical services for complex dental patient cases that require operating room access need specific Current Procedural Terminology (CPT) codes. Presently, coding for these covered dental surgical procedures is limited to an unlisted/miscellaneous code (CPT 41899), and for hospital outpatient payment purposes, has been placed with other miscellaneous codes in an APC (5161) with a national average 2020 Ambulatory Payment Classification rate of $203.64.

“This reimbursement level is grossly under the appropriate cost for complex dental surgery cases, and significantly less than national average geometric mean cost of the procedure being billed to Medicare,” the groups wrote, and “the current Ambulatory Payment Classification rate does not recognize or cover a facility’s time, expense, professional surgical services, anesthesia services or equipment costs.”

They noted that most state Medicaid programs look to Medicare payment policy and rates “as a benchmark for determining Medicaid policies for dental surgical services, increasing the magnitude of this access problem, particularly for children with special needs.”

ADA, AAPD and AAOMS concluded the letter by urging CMS to help solve these issues by establishing a Healthcare Common Procedure Coding System Level II code.

“We would like to work with CMS to explore this coding option further in an effort to improve beneficiary access to covered dental surgical services and in a manner that allows dentists the ability to choose to perform these procedures in hospital outpatient departments or ambulatory surgical centers,” they wrote.

On Sept. 21, the groups also sent a letter to the CMS Hospital and Ambulatory Policy group regarding a coding descriptor for a new Healthcare Common Procedure Coding System Level II code.

For more information on the ADA’s advocacy efforts, visit ADA.org/Advocacy .