CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Office-based general anesthesia and IV sedation by oral surgeons

Defines coverage for general anesthesia and intravenous sedation provided by oral surgeons in the office setting when performed in conjunction with a covered oral surgical CPT procedure; identifies covered and not-covered CDT anesthesia codes and billing instructions.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyOffice-based general anesthesia and IV sedation by oral surgeons

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionOral surgeon must submit the oral surgical CPT procedure code and the anesthesia/sedation CDT code on a CMS1500 form for BCBSRI medical coverage to ensure correct claims processing.

SourceLink

POLICY UPDATE CHANGES

No material changes — brief indicates no material clinical/coverage changes.

2Covered CDT anesthesia codes listed

2Not covered CDT anesthesia codes listed

Coverage Summary

Defines coverage for general anesthesia and intravenous sedation provided by oral surgeons in the office setting when performed in conjunction with a covered oral surgical CPT procedure; identifies covered and not-covered CDT anesthesia codes and billing instructions. Status: CURRENT. Coverage stance: covered_with_criteria.

Key Policy Facts

subjectOffice-based general anesthesia and IV sedation by oral surgeons

statusCURRENT

coverage_stancecovered_with_criteria

scope_summaryGeneral anesthesia and IV sedation by oral surgeons in the office are covered as a separate medical benefit only when performed with a covered oral surgical CPT procedure; specifies covered and not-covered CDT anesthesia codes and billing on CMS1500.

Covered CDT anesthesia codes listed2

Not covered CDT anesthesia codes listed2

Medical-Necessity Criteria

Medically Covered Scenario

Covered when ALL of the following are met:

ALL of the following

General anesthesia or intravenous sedation is provided by an oral surgeon in the office setting
Separate payment made for anesthesia services in the office setting
Anesthesia/sedation is performed in conjunction with a covered oral surgical CPT procedure code
Anesthesia/sedation CDT code (see coding) and the oral surgical CPT procedure code are submitted on a CMS1500 form for medical coverage

ref": "b1_0

title": "Medically Covered Scenario

title_ignored_for_schema_validation_do_not_use_x": "

ref_ignored_for_schema_validation_do_not_use_x": "

Not Covered / Member Liability

Not covered when ANY of the following apply:

ANY of the following

The anesthesia/sedation is provided in conjunction with a non-covered surgical procedure performed by an oral surgeon in the office setting
Result: not covered and member liability
The procedure code submitted is not a covered medical procedure
Anesthesia services will be denied

ref": "b1_1

title": "Not Covered / Member Liability

Coding

Covered CDT anesthesia codes (when filed with a covered medical CPT code)mixedCovered

D9223	Deep sedation/general anesthesia - first 30 minutes (CDT anesthesia code)
D9243	Intravenous moderate (conscious) sedation/analgesia — first 30 minutes (CDT anesthesia code)

Not covered CDT anesthesia codes (member liability)mixedNot Covered

D9230	Analgesia, anxiolysis, inhalation of nitrous oxide/analgesia, anxiolysis
D9248	General anesthesia — administration of general anesthesia

Provider Actions

Billing Rule

Submission of codes on CMS1500

Oral surgeon must submit the oral surgical CPT procedure code and the anesthesia/sedation CDT code on a CMS1500 form for BCBSRI medical coverage to ensure correct claims processing.

Denial Risk

Denial when procedure not covered

Anesthesia services will be denied if the submitted procedure code is not a covered medical procedure.

Documentation Required

Member liability when procedure non-covered

If anesthesia/sedation is provided with a non-covered surgical procedure, the service is not covered and is member liability unless prior agreement allows charging the member in writing.

Background

General anesthesia and intravenous sedation provided by an oral surgeon in the office setting is considered a separate covered service under the member's medical benefit when performed in conjunction with a covered surgical procedure. Payment is made under the medical benefit only when performed with covered oral surgical CPT codes.