Revisions to Sedation Codes
One of the most significant changes in CDT 2016 concerns the reporting of intravenous sedation and general anesthesia. In dentistry, sedation has historically been reported for the first 30-minute increment of sedation, then for each additional 15-minute increment. This previous method of reporting is now revised to be similar to medical reporting, where sedation is reported in 15-minute increments. To establish this new reporting method, four existing CDT codes were deleted, and two new codes were added to replace those deleted codes.
D9220 Deep sedation/general anesthesia – first 30 minutes
D9221 Deep sedation/general anesthesia – each additional 15 minutes
D9241 Intravenous moderate (conscious) sedation/analgesia – first 30 minutes
D9242 Intravenous moderate (conscious) sedation/analgesia – each additional 15 minutes
D9223 Deep sedation/general anesthesia – each 15 minute increment
D9243 Intravenous moderate (conscious) sedation/analgesia – each 15 minute increment
With the introduction of these two new sedation codes, some confusion has resulted on how to properly report them. Based on the 2012 ADA Dental Claim Form instructions, report the sedation code on a single line. Use Box 29b to indicate the “Quantity” of the procedure. For example, if 60 minutes of deep sedation is provided, report D9223 and enter “4” in Box 29b.
Despite having access to the quantity box on the claim form, not all payers recognize the information provided in Box 29b. According to one major software company, this box has been activated and any amount entered in the quantity box will be appropriately processed. However, others have not “activated” the box yet.
Two major payers have recently published their guidelines that establish how to properly report these new codes and how their fee schedules for these codes will be structured. Both payers have instructed that the codes will be reported “per line.” This means that 60 minutes of deep sedation should be reported by listing D9223 on the claim form on four separate lines.
If you find that your 2016 claims for sedation are being denied, change the method of reporting. If you followed the claim form instructions and entered the code once and indicated a quantity, try reporting the code on a separate line for each 15-minute increment.
One of the payers has further stated that any charges for more than 60 minutes of sedation will typically be disallowed. Sedation time required over 60 minutes may be considered on a “by report” basis. This limitation has been set based on the fact that not all dental procedures require sedation, and those that do can usually be completed in 60 minutes or less. Other payers have similar exclusions and limitations on anesthesia services. Review the processing policy manual for each payer to determine its specific limitations.
The fee schedules for two payers were determined by adding the previous allowance for the initial 30 minutes plus two 15-minute increments of additional time. The total was then divided by four to obtain the fee for each 15-minute increment. Therefore, this is the suggested method to use to adjust dental practice fee schedules.
CDT codes are updated annually. It is important to review all CDT code changes each year and to make sure you are prepared to report procedures using the current code set. Failure to do so can result in claim rejections.