CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Payment Policy Dental Procedures in the Outpatient Setting

Defines when facility charges for dental procedures performed outside a dental office (inpatient/outpatient hospital or ambulatory surgical center) are eligible for coverage under the medical benefit for members with qualifying medical conditions, and directs dental procedure professional charges to the dental benefit. Provides revenue and HCPCS code guidance for facility claims.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPayment Policy Dental Procedures in the Outpatient Setting

Policy CodePolicy N/A

Change TypeClarified (provider updates listed; no material coverage changes)

Effective DateJan 1, 2014

Next Review Date

Key ActionObtain prior authorization for BlueCHiP for Medicare (recommended for Commercial) and document the member's qualifying medical condition when dental procedures are performed in a facility setting.

SourceLink

POLICY UPDATE CHANGES

Policy last updated 01/16/2018 with provider updates listed historically; no specific clinical policy statement changes documented in the body.

10Example qualifying medical conditions listed

2Facility revenue codes listed

Policy summary

This policy covers when dental procedures performed outside the dental office (inpatient/outpatient hospital or ambulatory surgical center) may generate facility charges eligible under the member's medical benefit and directs dental professional procedure fees to the dental benefit. It applies when a member has a documented qualifying medical condition that necessitates treatment in a facility rather than a dental office.

PolicyPayment Policy Dental Procedures in the Outpatient Setting

PayerBlue Cross Blue Shield - Rhode Island

Policy NumberN/A

Effective Date2014-01-01

Last Review2018-01-16

StatusCURRENT

ScopeDefines when facility charges for dental procedures performed outside a dental office (inpatient/outpatient hospital or ambulatory surgical center) are eligible for coverage under the medical benefit for members with qualifying medical conditions, and directs dental procedure professional charges to the dental benefit. Provides revenue and HCPCS code guidance for facility claims.

Medical necessity criteria for facility setting

Medical necessity for facility setting

Facility charges are eligible for coverage under the medical benefit when ALL of the following apply:

Setting: Dental procedure is rendered in a setting other than the dental office (inpatient/outpatient hospital or ambulatory surgical center).
Qualifying medical condition documented
- Examples of qualifying medical conditions (any)
  - Heart disease, including congenital defects and prosthetic heart valve that require strict anticoagulation.
  - Blood dyscrasias, including coagulation defects.
  - Endocrine disturbances, including brittle diabetes and adrenal insufficiency.
  - Neuromuscular disease, including spastic paralysis and muscular dystonias.
  - Genetic disease, including fibrosis and cleft/cystic palate.
  - Pulmonary disease including asthma that cannot safely be managed in an office setting.
  - Intellectual disability (mental retardation) complicated by seizure disorders, cerebral palsy, or behavior disorders.
  - Severe emotional disturbance: Documented severe emotional disturbance/behavioral disorders.
  - Rampant caries (baby bottle): Rampant caries in a patient less than forty-eight (48) months of age (Baby Bottle Syndrome).
  - Extreme apprehension in children with documentation of unsuccessful attempt(s) at office treatment with sedation.
Billing allocation: If member has dental coverage, fees and charges specific to the dental procedure/service are eligible under the dental benefit; if member does not have dental coverage, dental procedure charges are the member's responsibility.

Facility and procedure codes

Outpatient Surgery Revenue Codes (facility)RevenueCovered

0361	Operating Room Services: Minor surgery
0360	Operating Room Services

HCPCS Dental Procedure Codes (facility note)HCPCS

List of HCPCS dental procedure codes typically used for dental procedures rendered in the outpatient setting (not an all-inclusive list) - specific codes are not enumerated in the policy text

Bill facility fees (for example, operating room, anesthesia, and medical consults) to the member's medical benefit and bill the professional dental procedure fees rendered by the oral surgeon/dentist to the dental benefit; if the member lacks dental coverage, dental procedure charges become the member's responsibility. Facilities are requested to use the specified Revenue Codes and HCPCS dental codes to ensure correct claim processing.

Note: prior authorization requirements apply (BlueCHiP for Medicare required; recommended for Commercial). This is a billing split guidance for coding and claim filing — it does not replace documenting the member's qualifying medical condition or other clinical/provider action requirements.

Billing, authorization, and documentation requirements

Prior Authorization

Prior authorization requirement

Prior authorization is required for BlueCHiP for Medicare and is recommended for Commercial products when dental procedures are to be performed in a facility setting.

Documentation Required

Document qualifying medical condition and prior office treatment attempts

Providers must document the member's qualifying medical condition that necessitates performing the dental procedure in a hospital/ASC setting. For children with extreme apprehension, providers must document unsuccessful attempt(s) at office treatment with sedation.

Document the member’s qualifying medical condition that necessitates the facility setting.
For extreme apprehension in children, document unsuccessful attempt(s) at office treatment with sedation.

Billing Rule

Facility vs dental benefit billing

Facility fees (operating room, anesthesia, medical consults) should be billed to the member's medical benefit using appropriate facility revenue codes; fees for the dental procedure performed by the oral surgeon/dentist should be billed to the dental benefit. If the member does not have dental coverage, dental procedure charges are the member's responsibility.

Affected facility revenue codes: 0361, 0360
Facility fees (OR, anesthesia, medical consults) → bill to the medical benefit.
Dental procedure professional fees (oral surgeon/dentist) → bill to the dental benefit.
If member lacks dental coverage → dental procedure charges are the member's responsibility.

Billing Rule

Use of specified revenue and HCPCS codes

To ensure correct claim processing, facilities are requested to use the listed outpatient surgery revenue codes and the HCPCS dental procedure codes when submitting facility claims for dental procedures performed in the outpatient setting.

Use the listed outpatient surgery revenue codes: 0361, 0360.
Use the applicable HCPCS dental procedure codes for outpatient dental services.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPayment Policy Dental Procedures in the Outpatient Setting

Policy CodePolicy N/A

Change TypeClarified (provider updates listed; no material coverage changes)

Effective DateJan 1, 2014

Next Review Date

SourceLink

On This Page

OpenPayer

Payment Policy Dental Procedures in the Outpatient Setting

Policy summary

Medical necessity criteria for facility setting

Facility and procedure codes

Billing, authorization, and documentation requirements

Key terms

Policy changes and review log