Dental services may qualify for payment as medical-surgical benefit

There has been confusion regarding benefit coverage when facility, anesthesia and dental procedure charges are interrelated in some way.

Blue Cross Blue Shield of Michigan dental programs are intended to cover treatment of the teeth and supporting structures. Typically, these services are payable as part of a member’s dental benefits and not as a medical-surgical benefit. Dental services may qualify for payment as a medical-surgical benefit if:

• They are part of the member’s benefit design and required criteria are met.
• A member is admitted as an inpatient to the hospital with a medical problem that is negatively impacted by a dental condition. Documentation shows that treating the dental condition is intended to improve the medical condition to facilitate discharge from the hospital.
• A patient requires prophylactic extractions before an organ transplant, cardiac valve surgery or ionizing radiation (5,000 cGy or more) that involves the jaw.
• Procedures are included in the accidental dental injury benefit. This benefit applies when a patient experiences an external force to the lower half of the face or jaw that damages or breaks the teeth, periodontal structures or bone (other than self-inflicted external force of chewing), or a medical condition.

Facility charges are part of the medical-surgical benefit when associated with dental procedures if circumstances prevent the dental procedures from being performed in an office setting. These circumstances include the following:

• A member is an inpatient with a medical problem that is impacted negatively by the dental problem — and treating the dental condition is intended to improve the medical condition to facilitate discharge from the hospital.
• A patient requires dental services and meets the anesthesia criteria for outpatient general anesthesia.

Anesthesia services would be payable to the anesthesiologist or certified registered nurse anesthetist under the medical-surgical benefit — in conjunction with billable procedures on the teeth and supporting structures — when those services are medically necessary and performed in a hospital setting. In such cases, the anesthesiologist or certified registered nurse anesthetist should submit procedure code *00170. The dental services rendered are not payable unless the member has the benefit.

Anesthesia is covered if the following criteria are met:

• The patient is a child younger than 7 years (i.e., through the end of the sixth year).
• For older patients, coverage depends on the extent of procedures required. At a minimum, the patient should have six or more teeth that need to be extracted or other procedures that must be performed in two or more quadrants of the mouth on the same date of service.

One of the following conditions must also be met:

• A concurrent hazardous medical condition that creates a documented medical necessity to safeguard the life of the patient must exist. This condition makes it medically necessary to perform the procedure in a facility under general anesthesia or sedation, such as severe cerebral palsy or labile hypertension with three or more antihypertensive medications must be documented in the patient’s record). Chronic stable medical conditions, behavioral concerns and situational anxiety do not meet the criteria for approval.
• Significant cellulitis or swelling and associated trismus that does not allow the use of local anesthesia
• Extensive oral-facial or dental trauma for which treatment under local anesthesia would be ineffective or compromised

Anesthesia charges are considered a medical-surgical benefit when the service performed is not reported with a procedure code from CPT Appendix G and when modifier 59 is indicated with procedure codes *99143-*99145. Procedure code *41899 and D dental codes are not payable in association with *99143-*99148 unless covered under the patient’s benefit plan.

For specific information about member benefits and eligibility, check web-DENIS or call PARS. Following is a general guide to help you administer the benefit:

**Group specific. Check PARS, web-DENIS or Provider Inquiry.

***Anesthesia is payable to surgeon if procedure codes *99143 through *99145 (appended with modifier 59) are billed with a procedure code not in CPT Apppendix G or with a D dental code or *41899 (unless certificate covers extraction of teeth).

****Facility charges are not payable if anesthesia is performed in the office setting.