ARCHIVED

Medical Policy

Policy Num:     13.006.001
Policy Name:    Visit to Ambulatory Surgical Center and / or Hospital
Policy ID:          [13.006.001]  [Ar / L / M+ / P+]  [13.006.001]

Last Review:      November 11, 2020
Next Review:      Policy Archived
Issue:                  11:2020

ARCHIVED

Related Policies BCBS: None

Related Policies TSSS: None

Visit to Ambulatory Surgical Center and / or Hospital

Summary

When a participating dentist leaves his office to perform dental services in an Ambulatory Surgical Center or Hospital.

Objective

This code D9420 is the payment for all administrative cost incurred by the participating dentist for leaving his office to perform the services to treat patients under general anesthesia in a Hospital or an Ambulatory Surgical Center due to; their age, physical or medical condition or complexity of the procedure. 

They only charge the insured for non-covered services.

Policy Statements

Code D9420 requires predeterminationand the required documents are;

(a)  patient’s diagnostic

(b)  medical condition of the patient

(c)  the reasons that justify  that the patient  receives general anesthesia

(d)  all other information that can help to the determination

Policy Guidelines

1.    Code D9420 requires predetermination, the required documents will be:

            (a) patient’s diagnostic

            (b) medical condition of the patient

            (c)  the reasons that justify that the patient receives general anesthesia

2.    It will be considered for payment one every six months per insured for dental services that are performed in the operating room under general anesthesia or in an ambulatory surgery center where the condition and circumstances of the patient does not allow to perform the services in the dental office and that the anesthesia considered as a last resort.

3.    The fee for code D9420 includes all administrative costs incurred by the participating dentist to perform the service in; Hospital  (operating room) or in an Ambulatory Surgical Center; he/she can only charge the insured for non-covered services.

4.    If there is a Medical Surgical service predetermination in the same day that a dental procedures will be performed, the code D9420  will be part of the fee of the main Medical Surgical procedure and cannot be charged to the insured. (Applies only to the specialty of the Oral and Maxillofacial Surgeon)

5.   If you are pre-authorizing dental services that are required to be performed in an Ambulatory Surgical Center or Hospital under general anesthesia and you are including a Medical Surgical service that may have been performed in an office, code D9420  may be considered for paym code to be covered. (Applies only to the specialty of the Oral and Maxillofacial Surgeon)

6.    When a pediatric dentist, oral  maxillofacial surgeon  member of the medical faculty of a hospital, licensed by the Government of Puerto Rico, in accordance with Law 75 of  August 8, 1925, as amended, determines that the condition or ailment of the patient is   significantly complex in accordance with the criteria established by the American Academy   of Pediatric Dentistry.

7.     When the patient for reasons of age, impairment or disability is unable to resist or tolerate pain, or cooperate with the treatment indicated in dental procedures.

8.    When the infant, boy, girl, adolescent or person with a physical or mental impairment has a medical condition in which it is indispensable to perform the dental treatment under general anesthesia in an ambulatory surgical center or in a hospital, and that otherwise it could represent a significant risk to the health of the patient.

9.    When local anesthesia is ineffective or contraindicated due to an acute infection, anatomical variation or      allergic condition.

10.When the patient is an infant, boy, girl, adolescent, person with a physical or mental impairment, and is in a state of fear or anxiety that prevents to perform dental treatment under the procedures of traditional use of dental treatments and his/her condition is of such magnitude, that delaying or deferring treatment would result in pain, infection, loss of teeth or dental morbidity.

11.When a patient has received extensive and severe dental trauma where the use of local anesthesia would compromise the quality of services or would be ineffective for managing pain and apprehension.

Policy #5 to the #10 belong to Law 352, (Article 1 - Coverage of Anesthesia and Hospitalization in Dental Procedures)

Benefit Application

BlueCard/National Account Issues

N/A

Background

This code is used to treat patient’s due to their age, physical conditions, medical condition or complexity of the procedure, when the services cannot be performed in a dental office.

Regulatory Status

N/A

Rationale

Is the fee for the dentist to close his office and transfer his services to perform dental services in hospital/ambulatory center, due, to their age, physical conditions, medical condition or complexity of the procedure, under general anesthesia.

Population Reference No. 1 

Individual: with Special needs that services have to be rendered in hospital/ambulatory center. Intervention of interest is: Visit to Ambulatory Surgical Center / Hospital. Comparators of interest; Service in Dental Office. Relevant outcomes include: Quality of Life, Secure Environment, Less traumatic, Less visits, Some cases the only place of service (medical health condition).

Population Reference No. 2 

Individual: With uncontrolled behavior in dental environment (childrens). Intervention of interest is: Visit to Ambulatory Surgical Center / Hospital. Comparators of interest; Service in dental office. Relevant outcomes include: Quality of life, secure environment, less traumatic, less visits and in  some cases the only place of service (medical health condition).

Population Reference No. 3 

Individual: Unusual complexity of procedure Intervention of interest is: Visit to Ambulatory Surgical Center / Hospital. Comparators of interest; Service in dental office. Relevant outcomes include: Quality of life, secure environment, less traumatic, less visits and in  some cases the only place of service (medical health condition).

Supplemental Information

N/A

Practice Guidelines and Position Statements

N/A

Medicare National Coverage

N/A

References

1. Participating Odontologist Manual 2019, Additional General Services, Rules and Limitations.

2. Participating Odontopediatric Manual 2019, Additional General Services, Limitations.

3. Participating Oral and Maxillofacial Surgeon Manual 2018, Additional General Services, Limitations.

4. Law 352, December 22, 1999.

5. Insured’s coverage certificate, General Exclusions of Basic Coverage.

Codes

Appplicable Modifiers

N/A

Policy History