A proposed rule from the Centers for Medicare & Medicaid Services would increase the facility fee for dental surgeries performed in hospital operating rooms, thereby increasing access to dental rehabilitation surgery for patients who need extensive dental procedures performed in operating rooms.
This change occurred after advocacy by the American Academy of Pediatric Dentistry, American Dental Association and American Association of Oral and Maxillofacial Surgeons. For example, in a letter to CMS dated June 30, the groups asked that the agency address the dental community's "significant concerns" regarding pediatric and adult patient access to dental rehabilitation surgery in hospital outpatient and ambulatory surgical center locations. The dental organizations noted that "limitations in access have been exacerbated" by the COVID-19 pandemic, primarily affecting high-risk Medicaid and commercially insured patients who require an operating room setting when receiving extensive dental procedures due to their particular medical conditions.
"The lack of OR access for needed and covered dental procedures often results in wait times of 6-12 months for these patients, many of whom are children whose daily activities and school performance are often significantly affected in the interim," the dental groups wrote. "We attribute most of this access challenge to the lack of a sustainable billing mechanism for hospitals and [ambulatory surgical centers] to report dental surgical services in both Medicare and Medicaid."
The CMS proposed to change the Medicare Ambulatory Payment Classification (APC) of CPT code 41899 (unlisted procedure, dentoalveolar structures), which is the code frequently used by hospitals to bill the facility fee for dental operating room cases. The code is currently assigned to APC 5161 (Level 1 ENT Procedures) whose payment rate is approximately $200, a rate that in no way reflects the average cost of the dental services it is meant to cover. CMS proposes to move the code to APC 5871 (Dental Procedures), which would raise the Medicare facility payment rate associated with this procedure code from $203.64 to $1958.92.
The proposed rule can be found online. The dental section begins on page 168 of the document.
If finalized in regulation, effective Jan. 1, 2023, this increased facility fee would apply to dental OR cases taking place in hospital outpatient settings for Medicare patients when CPT 41899 is billed. Many states use Medicare billing codes for Medicaid services and use the codes' assigned billing rates to guide Medicaid reimbursement.
The ADA will issue additional guidance and Q&A on implementation issues as this proposal moves forward in the regulatory process. Additionally, in ongoing conversations with CMS and Congress, the dental groups will continue to pursue efforts to establish a new HCPCS code for use within ambulatory surgery centers.
Follow all of the ADA's advocacy efforts at ADA.org/Advocacy.