The American Academy of Pediatric Dentistry (AAPD), American Dental Association (ADA), and the American Association of Oral and Maxillofacial Surgeons (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 surgical center (ASC) operating room (OR) time for dental cases requiring monitored anesthesia (e.g., general, intravenous sedation) and use of an operating room. This included recently submitting regulatory comments to CMS on its CY 2024 Proposed Rule on Hospital Outpatient and Ambulatory Surgical Center Payments Under Medicare. Click here for more background information.
It is important to understand that this initiative addresses the amounts payable to hospitals and ambulatory surgical centers (ASC) 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/ASC administrative costs and overhead costs. Dentists’ professional fees are separately billable and are not affected by this initiative.
We are pleased that the final CY 2024 CMS regulation just released officially approved the inclusion of HCPCS code G0330 (the new dental rehabilitation facility fee code approved by CMS under the Hospital Outpatient Payment Rule for CY 2023) on the covered procedures list for ASCs, consistent with the proposed rule. Other modifications in the proposed rule as recommended by AAPD-ADA-AAOMS were adopted.
Below is a very brief initial summation of the complex regulation, which is currently being carefully analyzed by AAPD, ADA, and AAOMS (hence, subject to additional clarification and possible edits):
- CMS originally proposed to reduce Medicare payment to hospitals for the facility costs associated with dental rehabilitation (HCPCS code G0330) from $1,722.43 in 2023 to $938.69 in 2024, a reduction of over 45%. As the result of the AAPD and coalition’s advocacy efforts, CMS reclassified G0330 into a higher payment category, as the AAPD requested. The final hospital facility payment rate is $3,070.81, beginning January 1, 2024. This hospital facility payment includes all dental procedures as well as other services that may be performed in conjunction with the dental rehabilitation, such as dental evaluation and imaging.
- For hospitals, G0330 is billable only if no other dental procedure that is separately payable under the hospital payment schedule (HOPPS) is performed. A number of commonly performed dental procedures are separately payable under HOPPS and many are separately payable. Based on our initial analysis, for typical pediatric dental cases, the total amount billable by a hospital for their facility costs for cases billed based on individual CDT codes will be significantly greater than the amounts payable prior to CY 2023, when far fewer CDT codes were billable.
- The 2024 ASC payment rate for G0330 is $1,318.93. This is also a tremendous boost from CMS’ original proposal, which would have allowed only $495.52. As in the hospital setting, G0330 is only billable if no separately payable CDT code is billable. However, there are only 26 dental procedures on the ASC list, so G0330 may be eligible for payment in an ASC setting more frequently than in the hospital outpatient setting.
- G0330 must be billed along with a dental procedure that is on the ASC ancillary services list, a list which includes dental evaluation and various imaging services, as well as a number of dental procedures.
- These new regulations cover Medicare, but Medicare coverage and payment levels may be followed/adopted by state Medicaid agencies (SMAs) as well as private insurers. AAPD is working with our state Public Policy Advocates (PPAs) network to promote adoption of changes by SMAs that increase facility fees for dental cases. AAPD’s RPC is collecting information on SMA payment for the hospital and ASC costs involved in the provision of dental services.
While hospitals and ASCs will be responsible for the submission of claims for dental cases that use their facilities, we anticipate that hospitals and ASCs may look to dentists or other specialists who perform these surgical cases for assistance in assuring that the coding is accurate. The AAPD will educate members about the nuances and implications for billing/coding hospital OR and ASC dental cases after the final rule takes effect on January 1, 2024. Look for more information shortly about an upcoming free educational webinar for AAPD members in early 2024.
For any questions, please contact Chief Operating Officer and General Counsel C. Scott Litch at 773-938-4759 or firstname.lastname@example.org.