AAPD-ADA-AAOMS have been working together in a concerted advocacy campaign to address the challenges pediatric dentists and other dentists around the country are experiencing in obtaining or maintaining hospital or ambulatory surgery center (ASC) operating room time for dental cases requiring care under general anesthesia.1
The Center for Medicare and Medicaid Services (CMS) issued a notice of proposed rulemaking on July 26, 2022 that (among a host of other matters) proposes 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 (OR) 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 providing facility-related (not dental professional) services it is meant to cover. CMS proposes to move the code to APC 5871 (Dental Procedures). This would have the effect of raising the Medicare facility payment rate associated with this procedure code from $203.64 to $1958.92.2
If finalized in regulation, effective January 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 also use the codes’ assigned billing rates to guide Medicaid reimbursement. AAPD will issue additional guidance and Q and A on implementation issues as this proposal moves forward in the regulatory process.
This CMS proposal is a result of a sustained advocacy effort and addresses hospital access for these important oral health services. Since the rule does not propose to establish a new HCPCS code for use within ambulatory surgery centers (ASCs), AAPD-ADA-AAOMS will continue to pursue this effort in our ongoing discussions with CMS and Congress.
This proposal was strongly supported in the following regulatory comment letters submitted to CMS by the September 13, 2022 deadline. The comment letters described below also asked CMS to work towards a solution for dental cases performed in ASCs.
1 For background information on these efforts see here.
2 For a copy of the proposed rule see here. The dental section begins on page 168 of the PDF at the link above.
- AAPD-ADA-AAOMS submitted a regulatory comment letter that was also endorsed by seven additional members of the Organized Dentistry Coalition. Click here for a copy of the letter.
- 22 Members of the Consortium for Constituents with Disabilities (CCD) Health Task Force submitted a comment letter. Click here for a copy of the letter. The AAPD is also a member of CCD.
- 20 Members of Congress submitted a comment letter. This effort was led by Congresswoman Terri Sewell (D-Ala. 7th) and Congressman/dentist Drew Ferguson (R-Ga.3rd). The AAPD applauds their leadership on this critical issue.
- Several AAPD state chapters submitted comments in support of the proposal.
- The proposal was also supported by the Ambulatory Surgery Center Association.
For any questions on this issue contact Chief Operating Officer and General Counsel C. Scott Litch at 773-938-4759 or firstname.lastname@example.org.