CMS releases final rule on payments for hospital outpatient and ambulatory surgical centers

Final rule takes effect Jan. 1, 2024

The Centers for Medicare & Medicaid Services released the 2024 Hospital Outpatient Prospective Payment System final rule, announcing it will finalize Medicare payment rates for more than 240 dental codes by assigning them to ambulatory payment classifications. Due to advocacy from American Dental Association, the American Academy of Pediatric Dentistry, and American Association of Oral and Maxillofacial Surgeons, the final rule provided clarification on how the Healthcare Common Procedure Coding System code G0330 should be used for dental rehabilitation, as well as eliminated proposed Medicare pay rate cuts associated with G0330.

CMS clarified that the G0330 code, under the Hospital Outpatient Prospective Payment System, should only be billed when no other specific CDT code is available. The agency recommended that CDT codes assigned to ambulatory payment classifications, which describe a specific service performed, should be used in billing for Medicare claims. The advocating organizations believe that these positive changes will contribute to alleviating the lack of access to hospital operating rooms for patients who need dental treatment in this setting.

The final rule also addresses the Ambulatory Surgical Center Payment System and adds 26 separately payable dental surgical procedures to the CDT Ambulatory Surgical Center Covered Procedures List and 78 ancillary dental services to the list of covered ancillary services to increase patient access. Multiple stakeholders, including the ADA, requested that the ancillary dental services on the covered procedures list be compensated similarly as procedures on the Hospital Outpatient Prospective Payment System, with exception to imaging and dental evaluation services. In a September 2023 letter to CMS, the ADA added, “We believe that to ensure equal access for both in-patient and out-patient settings, a similar list of CDT procedures barring any valid safety concerns should also be covered in the ASC setting.” 

ADA also requested that Healthcare Common Procedure Coding System code G0330 be reassigned to a new Ambulatory Procedure Classification in 2024. CMS’ proposed rule would have left dental rehabilitation in its current ambulatory payment classification and reduced the Medicare payment rate by 45 % in 2024. In a letter to CMS, the ADA said, “We are not confident, however, that there were in fact enough claims experience to support a reduction of the payment rate for G0330. We suggest that the agency revisit the payment rate and reconsider the analysis once sufficient claims volume is available for future analysis.” 

In response, CMS addressed this concern in the final rule and reclassified dental rehabilitation to APC 5164, which it said would “more appropriately” reflect the costs associated with services for dental rehabilitation procedures performed on a patient who requires monitored anesthesia. This change in the final rule resulted in the dental rehabilitation Medicare payment rate increasing from $1,722.43 in 2023 to $3,087.88 in 2024. 

Following the final rule, the ADA and two other organizations that submitted comments on the rule – the American Academy of Pediatric Dentistry and the American Association of Oral and Maxillofacial Surgeons – released a statement further explaining the rule. 

“It is important to understand that this initiative addresses the amounts payable to hospitals and ambulatory surgical centers for the facility costs they incur in making ORs available for dental procedures including, for example, the costs associated with equipping and staffing ORs, hospital administrative costs and overhead costs. Dentists’ professional fees are separately billable and are not affected by this initiative,” the statement reads. 

The groups go on to share support for the changes included in the final rule. 

“We are pleased that the final CY 2024 CMS regulation just released officially approved the inclusion of HCPCS code G0330,” they said. “Other modifications in the proposed rule as recommended by AAPD-ADA-AAOMS were adopted.”

Follow all the ADA’s advocacy efforts at ADA.org/Advocacy.