HealthCare News

Changes to Oral Surgeons and Dentists Billing for Moderate/Conscious Sedation Services

Issue: #397 NOV2017

Topic: Coding/Billing


Blue Cross Blue Shield of North Dakota (BCBSND) made the following changes to billing and coding for moderate (conscious) sedation anesthesia services for medical claims when billed by the operating oral surgeon or dentist. Effective for dates of service starting July 1, 2017, the following guidelines will apply only to claims processed by BCBSND for medical services:

  • Moderate (conscious) sedation, must be billed with the appropriate CDT® code developed by the ADA for this service. Claims not meeting this requirement will be returned for correction.
  • Oral surgeons and dentists may bill for moderate (conscious) sedation (D9243) administered during the surgery by the oral surgeon or dentist. Moderate (conscious) sedation is described as a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accomplished by light tactile stimulation and which no interventions are required to maintain a patient’s airway.
  • The provider number of the provider administering the anesthesia is required on the medical claim (CMS-1500).

Moderate Sedation (D9243): Intravenous moderate (conscious) sedation/analgesia – each 15-minute increment. Anesthesia time begins when the doctor administering the anesthetic agent initiates the appropriate anesthesia and non-invasive monitoring protocol and remains in continuous attendance of the patient. Anesthesia services are considered completed when the patient may be safely left under the observation of trained personnel and the doctor may safely leave the room to attend to other patients or duties. The level of anesthesia is determined by the anesthesia provider’s documentation of the anesthetics effects upon the central nervous system and not dependent upon the route of administration.

To submit a claim, the provider must:

  • Submit the claim on a CMS-1500 claim form.
  • Include the CDT® code for each service.
  • Include the tooth number in Box 19, Additional Claims Information.
  • Include appropriate ICD-10-CM diagnosis code.
  • Include the billing provider’s NPI number in Box 33A.

Please remember that if more than one surgical procedure is performed under anesthesia and not all procedures are allowed, the time for the anesthesia must be prorated for each service. This is required by BCBSND for claims processing.

Exception: Does not apply to FEP. Some self-funded groups may follow different guidelines depending on their benefit structure.

Example:

Dr. B, an oral surgeon, had a patient scheduled to have a surgical extraction of an impacted tooth. The patient came in and had the tooth removed. Dr. B administered the anesthetic agent at 10:15 a.m. and remained with the patient. The procedure was completed and Dr. B was able to safely leave the room at 10:47 a.m.

When billing for this procedure, Dr. B would bill the following:

  • D7220 Removal of Impacted Tooth – Soft Tissue – 1 unit
  • D9243 Intravenous Moderate (Conscious) Sedation – 2 units

The total anesthesia time was 32 minutes (10:15 a.m. to 10:47 a.m.). Using the scale provided as a part of the 2017 Reimbursement Notice, anesthesia time that meets or exceeds 23 minutes, but is less than 38 minutes = 2 billable units.