The American Academy of Pediatric Dentistry, American Dental Association and American Association of Oral and Maxillofacial Surgeons are asking the Centers for Medicare & Medicaid Services to help improve access to dental surgical services for children and adults with special needs and disabilities.
In a June 30 letter to Meena Seshamani, M.D., Ph.D., deputy administrator and director, CMS Center for Medicare, and Daniel Tsai, deputy administrator and director, CMS Center for Medicaid and CHIP Services, the groups asked the agency for a meeting to 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.
They noted that "limitations in access have been exacerbated" by the 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. They also said that other stakeholders have raised these same concerns - notably, the Consortium for Citizens with Disabilities Health Care Task Force and American Academy of Pediatrics - and Members of Congress have also requested action by the agency. The latter sent a May 25 letter to CMS Administrator Brooks-LaSure emphasizing the urgency of the dental access problem and its consequences on health equity.
"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."
To fix the issue, the groups said they believe "the hardship experienced by our patients" could be considerably alleviated by the issuance of a new Healthcare Common Procedure Coding System codes for dental surgical procedures performed under general anesthesia and payment for the new code at a rate that reflects the costs involved, based on Medicare data.
The dental groups noted that the problem is twofold: First, dental rehabilitation surgical services for complex dental patient cases that require operating room access do not have specific CPT codes. And secondly, because Medicare regulations do not allow miscellaneous codes to be included on the Covered Procedures List for Ambulatory Surgery Centers, these dental surgical services are not covered in the ambulatory surgical centers.
"While Medicare's coverage of dental surgical procedures is admittedly limited, these issues impact almost all of those Medicare patients whose dental surgery is performed ancillary to a covered surgical procedure," they wrote. "Our organizations are not otherwise requesting any expansion of Medicare dental services to address this situation."
The groups also said that "even more significantly, Medicaid programs often either adopt Medicare payment rates or utilize them as a benchmark, and both Medicaid and commercial payers generally utilize Medicare's [ambulatory surgery centers] list to determine which procedures are eligible for coverage. The lack of appropriate payment and the absence of these procedures on the ambulatory surgery center list, therefore, has a significant ripple effect on OR access for Medicaid patients."
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