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    v1.0.30
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyLouisiana Medicaid ASC Dental Coverage | OpenPayer
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    CurrentLouisiana Department of HealthPolicy 25-13

    Ambulatory Surgical Centers (Hospital Outpatient and Non-Hospital) Dental Procedure Codes

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    This policy explains Louisiana Medicaid coverage and billing requirements for dental procedure facility services furnished by hospital outpatient and non-hospital ambulatory surgical centers. It addresses HCPCS G0330, CPT 41899, and the separate billing of dental professional and anesthesia services.

    Policy Summary
    PayerLouisiana Department of Health
    PolicyAmbulatory Surgical Centers (Hospital Outpatient and Non-Hospital) Dental Procedure Codes
    Policy CodePolicy 25-13
    Change TypeAdded
    Effective DateJanuary 1, 2024
    Next Review DateNot specified
    Key ActionBill HCPCS G0330 only for qualifying ASC dental rehabilitation facility services requiring monitored anesthesia and an operating room.
    SourceLink
    POLICY UPDATE CHANGES

    HCPCS G0330 was added as a covered ambulatory surgical center service for qualifying dental rehabilitation procedures.

    G0330Covered ASC facility code added for qualifying dental rehabilitation
    41899Covered code for unlisted dentoalveolar procedures
    2 ASC settingsHospital outpatient and non-hospital facilities addressed

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    Separate billing
    Dental professional and anesthesia services are not included in G0330

    Covered Service Criteria

    HCPCS G0330 Coverage Criteria

    G0330 is covered when all applicable facility-service criteria are met.

    ALL of the following

    • ALL of the following

      • The service is a dental rehabilitation procedure.
      • The patient requires monitored anesthesia, including general anesthesia or intravenous sedation (monitored anesthesia care).
      • An operating room is used.
      • The claim is for the technical facility component furnished by a hospital outpatient or non-hospital ambulatory surgical center.

    CPT 41899 Reporting Criteria

    CPT 41899 remains covered when used as an unlisted code only because no existing code accurately describes the performed service.

    ALL of the following

    • The procedure is performed on the teeth or adjoining alveolar structures.
    • No existing CPT or HCPCS code accurately describes the medical procedure performed.
    • The facility selects the CPT or HCPCS code that most accurately describes the service rendered and submits CPT 41899 only when no existing code applies.

    Covered Codes

    Covered ASC dental rehabilitation facility serviceHCPCSCovered
    G0330Facility services for dental rehabilitation procedures provided to patients who require monitored anesthesia and use of an operating room; reports the technical facility component furnished by hospital outpatient and non-hospital ASCs.
    Covered unlisted dentoalveolar procedureCPTCovered
    41899Unlisted procedure for dentoalveolar structures, used for procedures on teeth and adjoining alveolar structures when no existing code accurately describes the medical procedure performed.

    Billing and Reporting Requirements

    Billing Rule

    Bill G0330 for Qualifying ASC Facility Services

    Bill HCPCS G0330 for qualifying ASC facility services for dental rehabilitation procedures when the patient requires monitored anesthesia—general or intravenous sedation/monitored anesthesia care—and use of an operating room.

    • Effective January 1, 2024, G0330 is a covered ASC service for both outpatient hospital and non-hospital ASCs.
    • G0330 reports the technical facility component furnished by the ASC.
    Billing Rule

    Separate Professional and Anesthesia Billing

    Report the dental professional and anesthesia services separately. HCPCS G0330 describes only the ASC's technical facility component and does not include the professional services of dentists or anesthesia providers.

    • Bill dental professional services separately.

    Code Definitions

    HCPCS G0330 Definition
    CodeHCPCS G0330
    DefinitionFacility services for dental rehabilitation procedures provided to patients who require monitored anesthesia, including general anesthesia or intravenous sedation (monitored anesthesia care), and use of an operating room.
    Component reportedTechnical facility component furnished by hospital outpatient and non-hospital ambulatory surgical centers.
    Not includedProfessional services of dentists or anesthesia providers; dental professional services and anesthesia fees must be billed separately.
    CPT 41899 Definition
    CodeCPT 41899
    Policy Summary
    PayerLouisiana Department of Health
    PolicyAmbulatory Surgical Centers (Hospital Outpatient and Non-Hospital) Dental Procedure Codes
    Policy CodePolicy 25-13
    Change TypeAdded
    Effective DateJanuary 1, 2024
    Next Review DateNot specified
    Key ActionBill HCPCS G0330 only for qualifying ASC dental rehabilitation facility services requiring monitored anesthesia and an operating room.
    SourceLink
    On This Page
    Covered Service CriteriaCovered CodesBilling and Reporting RequirementsCode Definitions
  1. Bill anesthesia provider fees separately.
    2. Billing Rule

    Apply Accurate-Code and Unlisted-Code Rules

    Always select the CPT or HCPCS code that most accurately describes the service rendered. Use an unlisted procedure code only when no existing code accurately describes the procedure performed.

    • CPT 41899 remains a covered Louisiana Medicaid code for an unlisted procedure involving dentoalveolar structures.
    • Use 41899 for a procedure on the teeth and adjoining alveolar structures only when an existing code does not accurately describe the medical procedure.
    • Do not submit an unlisted procedure code when an existing CPT or HCPCS code accurately describes the service.
    Definition
    An unlisted procedure for dentoalveolar structures.
    Anatomic siteProcedure on the teeth and adjoining alveolar structures.
    Use whenNo existing CPT or HCPCS code accurately describes the medical procedure performed.