Director of the Research and Policy Center American Academy of Pediatric Dentistry University of North Carolina
Disclosure(s):
Chelsea Fosse, DMD, MPH: No financial relationships to disclose
Abstract:
Objective: Operating room (OR) wait times for dental cases have skyrocketed in recent years, forcing patients – such as children with severe early childhood caries and/or people with disabilities – to wait too long to get care. A primary reason for the reduction in case availability is the inadequate reimbursement rates these facilities (hospitals and ambulatory surgical centers [ASCs]) received, leading them to prioritize more lucrative procedures. In 2023, CMS established a mechanism via Medicare payment systems to more fairly reimburse facilities for dental OR cases using a new billing code (G0330, HCPCS). Use of this code is now dependent on its adoption by state Medicaid agencies.
Methods: We monitor state Medicaid fee schedules and provider communications for updates pertaining to facility fee implementation for dental cases in OR settings: the billing code(s) adopted, settings in which those codes are reimbursable (hospital vs. ASC), and associated payment rates or ranges.
Results: As of Fall 2024, 29 states had implemented a facility fee for dental cases in ASCs, the vast majority setting payment rates at least 70% of the established Medicare rate. Slightly fewer (21) states have implemented a billing code for hospitals, and only 5 of those are near the Medicare rate.
Conclusions: Medicaid implementation of facility fees for dental cases in OR settings has rapidly progressed in the past few years. State adoption for ASCs has outpaced that of hospital ORs. Future research will focus on the impact of these coding and payment policies on wait times for patients.
