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ADA, AAPD ask CMS to update Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System

Two organizations request meeting with agency to improve dental access to operating rooms

October 06, 2020

By Jennifer Garvin

Washington — The ADA and American Academy of Pediatric Dentistry are asking the Centers for Medicare and Medicaid Services to update the Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System in order to improve patient access to dental procedures in hospitals and surgery centers.

In an Oct. 2 letter to CMS administrator Seema Verma, ADA President Chad P. Gehani and AAPD President Jessica A. Lee broke down how the Medicare payment policies under the current payment systems are “significantly” impacting patient access to dental procedures that require the use of hospital or ambulatory surgery center operating rooms.

In the letter, Drs. Gehani and Lee said the current Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System are impacting patients and providers in two ways.

First, the fact that ambulatory surgical centers and hospitals typically only have one Current Procedural Terminology (CPT) code to report dental procedures; the unlisted CPT code: 41899.

“Medicare regulations preclude the inclusion of unlisted CPT codes on the ambulatory surgical center list,” wrote Drs. Gehani and Lee. “This limitation not only impacts Medicare beneficiary access to ambulatory surgical centers for dental procedures, but also impacts access for many pediatric patients in need of major dental rehabilitation, since some states reimburse ambulatory surgical centers only for CPT codes on Medicare’s ambulatory surgical center list.”

The second issue is that under the Hospital Outpatient Prospective Payment System, the Medicare payment associated with dental surgery procedures “is only $206.14, an amount which is utterly insufficient to cover the facility costs involved.”

“These problems with reimbursement have resulted in many dentists, especially pediatric dentists, experiencing major difficulty in obtaining operating room time to perform surgical procedures under general anesthesia,” Drs. Gehani and Lee wrote. “This problem has now been exacerbated by the COVID-19 pandemic, with further limited access to operating rooms to address patient dental needs.”

“We all agree that oral health is an integral component of systemic health and that dentistry is an essential health care service because of its role in evaluating, diagnosing, preventing and treating oral diseases, which affect overall health. In order to prevent limitations on essential dental care from taking place, especially during a pandemic, the ADA and the AAPD request the opportunity to engage with you to discuss these issues in more detail in the coming months,” the letter concluded.

Follow all of the ADA’s advocacy efforts at ADA.org/advocacy.