SR 9240EK Dentalanesthesiasedation
User Manual: SR-9240EK
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DENTAL ANESTHESIA/SEDATION
Provider type 03 (Dentist) is eligible for payment only for general anesthesia, intravenous sedation, conscious sedation,
and nitrous oxide provided in the dentist's office or dental clinic (Procedure code D9220 - General Anesthesia, D9240 -
Intravenous Sedation, X9631 - Conscious Sedation, or X9632 - Nitrous Oxide) in conjunction with a compensable
surgical procedure.
Procedure codes X9631 (Conscious Sedation) and X9632 (Nitrous Oxide) are only compensable for eligible individuals
under 21 years of age. These procedure codes are compensable in conjunction with the dental treatment of the mentally,
physically, or medically compromised individual or those whose psychological or emotional maturity limit the ability to
undergo successful dental treatment.
Provider type 03 (Dentist) is not eligible for payment for anesthesia/sedation services provided in a hospital short
procedure unit, a hospital emergency room, an ambulatory surgical center, or on an inpatient hospital basis.
Payment for any one of the following procedure codes D9220 (General Anesthesia), D9240 (Intravenous Sedation),
X9631 (Conscious Sedation), X9632 (Nitrous Oxide), and X6940 (management fee) precludes payment of any of the
remaining codes on the same date of service.
The person responsible for the administration of the General Anesthesia, I.V. Sedation, Conscious Sedation, and Nitrous
Oxide must be in compliance with all rules, regulations, certifications, and licensure as indicated by the Pennsylvania
State Board of Dentistry. DENTAL
Dental - General Payment Policies
All dental procedures are considered to be outpatient procedures. These procedures are not compensable on a
inpatient basis unless there is medical justification which is documented in the patient's medical record.
Provider types 03 ( Dentist) and 01 ( Physician) are the only provider types eligible to receive payment for dental
services.
Provider type 01 (Physician) is eligible for payment onlyfor procedures coded D7450 through D7470, D7960, and
D7970. (This does not exclude provider type 03 - Dentist.)
Provider type 03 (Dentist) who is a board certified or board eligible orthodontist is the only provider type eligible
for payment of orthodontic services.
Orthodontics
Orthodontic services covered under this program must not be done solely for cosmetic purposes, but must be done
in conjunction with craniofacial reconstruction and/or the correction of a severe handicapping malocclusion.
Anesthesia
Provider type 01 (Physician) is the only provider type eligible for the anesthesia allowance when provided in a
hospital short procedure unit, ambulatory surgical center, emergency room, or inpatient hospital.
Provider type 03 (Dentist) is eligible for payment only for procedure code D9220 for general anesthesia services.
X9631 for Conscious Sedation, X9632 for Nitrous Oxide, or D9240 for intravenous sedation provided in a dentist's
office or a dental clinic.
Crowns
Procedure codes D2710 through D2791 are compensable only for fully developed permanent teeth and primary
teeth with no permanent successors. Payment is not made for prefabricated and/or self-curing dental materials.
Procedure codes D2930 - D2933 and D2336 are crowns for primary or developing permanent teeth only, and are
not compensable with construction of a permanent crown.
Revised 07/01/1999
Dentures
A partial denture which replaces only posterior permanent teeth must include three or more teeth on the dentures
which are anatomically correct (natural size, shape and color) to be compensable (excluding third molars).
The fees for dentures and partial dentures include all necessary adjustments and/or denture relines during the six (6)
month period following insertion of the denture.
Denture Relines
Chairside Reline - includes the use of light cured, self-curing and/or cold cure material in which the reline material
is utilized as the impression material.
Laboratory Reline - includes the use of an impression material technique from which a model is poured, mounted
and upon which the reline material is cured. The reline material is not utilized as the impression material.
The use of tissue conditioners and temporary liners is not compensable.
Restorations
Two or more restorations on the same surface of a tooth are considered as one restoration.
To bill for two or more restorations on one tooth, use the appropriate multiple procedure code.
The fees for restoration and filling include local anesthesia, polishing, bonding agents, cement bases, acid etch, light
cured material, and the necessary medication where indicated.
Management Fee
The management fee is limited to 2 per 365 days.
Payment for the management fee precludes payment for outpatient general anesthesia, intravenous sedation,
conscious sedation, or nitrous oxide on the same date of service.
Sealants
Payment for sealants, payable at the fee of $14.00 per permanent first molar (tooth numbers 3, 14, 19, 30) and
permanent second molars (tooth numbers 2, 15, 18, 31) for individuals under 21 years of age. Payment is limited to
one application per caries-free and restoration-free permanent molar, per lifetime.
Prior Authorization
All dental procedures are considered to be outpatient procedures. These procedures are not compensable on an
inpatient basis unless there is medical justification which is documented in the patient's medical record. All
inpatient requests require prior authorization.
Types of Service OA -- Crowns only 20 -- Surgery
OB -- Prosthodontic 21 -- Oral surgery, Extractions
OD -- Orthodontic 25 -- Surgical Diagnostic
OE -- Basic Dental 40 -- Anesthesia
10 -- Assistant Surgeon CP -- Cleft Palate
Revised 07/01/1999
