Anesthesia Coding Alert

Although many medical plans used to include coverage for dental services, that's rarely the case these days, and reimbursement for anesthesia during dental procedures can be unreliable. By knowing which set of codes the carrier wants and what type of documentation it requires, you're one step closer to being reimbursed.

The most frequent problem many coders have with dental reimbursement is the carrier's questioning the need for anesthesia at all.

 As with any case, ensure that documentation shows medical necessity for performing the services under anesthesia. The complexity of the procedure as documented by the dentist and/or oral surgeon combined with the anesthesiologist's documentation should be thorough enough to substantiate your claim, says Valerie Puckett, BS, CPC, manager of compliance and reimbursement, professional services, of St. Jude's Children's Research Hospital in Memphis, Tenn.                                                                                          

What types of situations help support anesthesia's necessity? Sometimes the patient's age or health status justifies it no matter what procedure the dentist or oral surgeon performs.

Puckett's practice sees many children who require sedation or anesthesia for dental procedures. Many of the children at St. Jude's require fillings, crowns and tooth extractions as a result of radiation oncology and chemotherapy," she explains. Because a dentist or oral surgeon performs these types of procedures as part of cancer treatment, the patient's medical insurer usually covers them, and standard medical rules apply.                                                                                  

 "Most of our procedures are performed under general anesthesia due to the patient's age," Puckett says. "We may also provide anesthesia if the patient is uncooperative or if there will be multiple extractions, root canals or other procedures during the same session."                                                                         

Patient preference may influence whether anesthesia is used during a procedure, says Gerry Malloy, coder with Lehigh Anesthesia Associates in Allentown, Pa. And from a practical standpoint, he adds that some dentists find that they can complete more cases if a separate anesthesia provider is involved.

The most appropriate codes to use and the likelihood of reimbursement largely depend on whether you're dealing with a medical plan or a dental plan.          

"Dental plans are usually only familiar with the HCPCS dental codes," Malloy says. "We usually have to bill with dental codes D9220 (Deep sedation/general anesthesia first 30 minutes) and D9221 ( each additional 15 minutes), though they don't have very good reimbursement." (Several other HCPCS codes relate to dental anesthesia, but D9220 and D9221 describe the most common procedures.)

 If a medical plan covers the procedure instead of dental, Malloy bills with ASA or CPT surgical codes, depending on the carrier's requirements. Anesthesia coders use 41899 (Unlisted procedure, dentoalveolar structures) and 00170 (Anesthesia for intraoral procedures, including biopsy; not otherwise specified) most often in this

 "Medical plans seem to be leaning more toward requiring anesthesia codes," Malloy says. "Whichever type of plan you're dealing with, you need to clearly understand its provisions for anesthesia provided by the anesthesiologist or CRNA. Delta Dental is one of the country's largest dental plans, and about 90 percent of the plan will only pay the dentist if he administers the anesthesia they won't pay to have a separate anesthesia provider during the procedure."

The preference for HCPCS or CPT codes may also depend partly on the types of services the anesthesiologist provides overall. For example, some groups find that mixing dental and CPT codes doesn't work well when the physician mainly performs CPT-type procedures. Surgical codes such as 41899 are often the best option for those physicians.

Aside from issues related to medical versus dental plans, the type of dental work performed also affects reimbursement. Dental plans usually cover general dentistry services (such as extractions). On the other hand, patient's medical plans usually reimburse for trauma services (such as treatment for jaw fractures or lacerated gums or lips). The medical plans often cover bony impactions because they can pose health concerns.                                                                                      

 "I find it easiest to get paid by primary or secondary medical plans if the patient has bony impactions," Malloy says. "These kinds of trauma services normally have higher reimbursement under medical plans because they're paid like a standard medical benefit. If the dentist performs simple or surgical extractions, it's very unlikely that a medical plan will pay the anesthesiologist anything at all."        

Many Medicare carriers and other insurers, however, will pay for tooth extractions that help facilitate other types of treatment. For example, teeth may be extracted so they won't be damaged by radiation or other treatments for cancer of the mouth or throat.

The fine print of policies can include some unusual regulations, so knowing what type of anesthesia reimbursement to expect from a carrier is an advantage. For example, Malloy knows of one carrier that will pay for dental anesthesia only if the dentist extracts more than three teeth from the same quadrant. Another will pay for anesthesia during simple extractions if the dentist removes more than two teeth at the same time. In terms of actual reimbursement, one carrier pays a maximum of $16 for dental anesthesia, while another pays a maximum of $60.

Correct coding and reimbursement for dental services often hinge on provisions in a particular group plan's policy. Malloy and Puckett offer these tips regarding successful dental anesthesia coding: