Answer:

The new HCPCS code G0330 for dental rehabilitation services covers the facility fee and will result in a payment of such fee to the hospital. Payment for dental professional services is billed separately and will be determined based on the type of coverage (and coverage terms) for the patient, whether the patient is covered by public or private insurance, a stand-alone or an embedded dental plan.

Answer:

HCPCS code G0330.

Answer:

Hospitals may receive updates from hospital associations and/or CMS. Anyone may sign up for CMS alerts at www.CMS.gov. However, dentists and dental advocates should also be proactive in alerting their department heads and local hospital administrators about the new code.

²Hospitals may have seen the CMS release Hospital Outpatient Prospective Payment System: January 2023 Update: https://www.cms.gov/files/document/mm13031-hospital-outpatient-prospective-payment-system-january-2023-update.pdf. There is discussion of G0330 on pages 5-6 under heading “6. Dental Coding Updates.”

Answer:

The published national average rate for HCPCS code G0330 is $1,722.43; however, the actual amount will vary based on the hospital’s geographic location and other factors.

Answer:

The new code and new rate applies to hospital facility fees for patients covered under the Medicare program (except for patients in the state of Maryland, because that state has its own system for paying for hospital services, including hospital outpatient services). It may also be applicable for patients with Medicaid coverage in states where the Medicaid program utilizes the HCPCS system and bases state Medicaid payment for hospital outpatient services on Medicare rates. See response to question 7 below.

Answer:

Private payers are not required to recognize the new code and payment rate, but they have the option to do so. Historically, private insurers tend to adopt changes made in public programs over time. Dental advocates are strongly encouraged to petition for adoption of the new code. The AAPD, ADA, and AAOMS will be communicating with major insurers to alert them to the new code and make this request.

Answer:

Possibly. Because each state Medicaid program is run differently, the adoption of this new code will depend on the state, and it is difficult to generalize in the FAQ. We encourage the dental advocates in each state to work together to advocate for these changes, in the way that best benefits that state.

To assist with this advocacy, the AAPD, ADA, and AAOMS are developing a guide for state dental advocates, starting with a recently released sample letter that should be sent to the SMA. However, advocates should personalize this letter as needed.

While it may be more difficult to persuade those SMAs that do not utilize the HCPCS code or that do not base Medicaid rates on those paid by Medicare, dental advocates still may be able to use CMS’s decision to increase facility payment for dental procedures as grounds for beginning a conversation with their SMA.

Answer:

As noted above, follow up advocacy will be required for private payers and state Medicaid programs to recognize the code and to increase hospital facility payment rates. It is important to note that if patients have separate medical and dental insurance – as is the most common situation – G0330 would be billed by the hospital under the patient’s medical insurance.

Answer:

Anesthesia fees are typically separate from facility fees. In most cases, the anesthesia fees and an anesthesiologist’s professional service fees will not be impacted by the new code and rate change.

The new HCPCS G-code is for “facility services for dental rehabilitation procedure(s) furnished to patients who require monitored anesthesia (e.g., general, intravenous sedation (monitored anesthesia care)) and use of an operating room [emphasis added].” It does not alter the payment rates for dental and anesthesia services provided. The procedures performed – dental and anesthesia – during the case are included on claims in addition to G0330 in applicable cases. The primary anticipated impact of the code is that it promotes hospital scheduling and block OR time for dental cases. It makes it financially feasible for hospitals to allocate OR dental time to dental cases.

Answer:

Not necessarily. Hospitals are considered “providers” just as dentists are considered “providers.” The new code (G0330) pertains to the hospital facility fee, and nearly all hospitals participate in the Medicare and Medicaid programs and other networks. Therefore, the hospital may submit G0330 on the claim form regardless of the dentists’ participation in these networks. However, a dentist who provides services in a hospital OR will be required to provide his or her NPI to the hospital for billing purposes and will be required to meet hospital requirements to obtain staff privileges.

Answer:

No. The dental benefits provided under Medicare to patients who require certain procedures (including organ transplants, cardiac valve replacement, and valvuloplasty) were expanded under the Calendar Year 2023 Physician Fee Schedule rule, which is a separate regulation. The new code described in this FAQ for dental surgeries in a hospital operating room is not limited to patients needing an organ transplant, cardiac valve replacement, or valvuloplasty. However, the expansion of the Medicare dental benefit to patients with those conditions is an additional reason why a hospital should recognize this new code, as patients who are newly eligible for dental treatment may need to have their dental care performed in the hospital’s operating room.

Answer:

Some electronic health records and electronic dental records have algorithms built into their software where ICD diagnostic codes that are commonly associated with the CPT or CDT procedural code populate, either one very commonly associated code or a relatively short list from which the provider selects the most appropriate diagnosis for their patient’s case. While this streamlines the note-taking administrative process, it is important for the dentist provider to pay close attention to the diagnostic code selected or pre-populated. The diagnostic code is part of the clinical note that is signed by the provider.

There are a wide variety of diagnoses – both medical and dental – that could predicate having dental treatment under general anesthesia in a hospital outpatient operating room setting. The need for this treatment could be due to the patient having an intellectual or developmental disability (e.g. ICD F70-79 series)³ This could be due to a behavioral or emotional disorder (e.g. F98 series). This could also be necessary due to the complexity of the dental treatment needed (K series).

We recommend dental providers consult with their patient’s primary care provider to determine the most appropriate diagnostic code. We also expect that EHR/EDR vendors will soon populate some diagnostic codes that would reasonably and appropriately be submitted with G0330.

³ Autistic disorder - F84 series, cerebral palsy - G80 series, Down’s syndrome - Q90 series, as examples.

Answer:

Not at present. However, the AAPD, ADA, AAOMS and other advocacy partners will strongly urge CMS to include the new code on the ASC CPL in the CY 2024 CMS rule being developed in 2023.

Answer:

Yes, and dental advocates should strongly encourage them to do so. Dental advocates may wish to inform any payer (including any state Medicaid program) that has historically provided ASC payment for CPT 41899 (Miscellaneous Dental Procedures, i.e. the CPT code that historically has been reported for dental procedures) that dental procedures requiring general anesthesia are to be reported under HCPCS code G0330 beginning January 1, 2023, and that the national average rate associated with these procedures under G0330 has increased substantially. For example, North Carolina adopted the G0330 procedure code in NC Medicaid for services provided in an ASC, effective January 1, 2023.⁴

⁴https://medicaid.ncdhhs.gov/blog/2022/12/21/new-procedure-code-facility-services-dental-rehabilitation-cases-ambulatory-surgical-center

Answer:

No. However, if a state Medicaid program has historically recognized CPT 41899 in the ASC setting, dental advocates should inform the Medicaid agency that G0330 should be used instead beginning on and after January 1, 2023, and that Medicare has increased the hospital average facility rate for these procedures under the new code.

Answer:

The national average Medicare rate of $1722.43 would be a starting point for negotiations; however, please note that dental advocates in Michigan have managed to negotiate rates that exceed Medicare’s national average payment rate and included both hospitals and ASCs!