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Provider Notice issued 11/30/04
Addition of Dental Procedure Codes to the Ambulatory Procedures Listing (APL)
| To: | Enrolled Hospitals: Chief Operating Officers, Chief Financial Officers, Patient Accounts Managers, and Health Information Management Directors; and Ambulatory Surgical Treatment Centers (ASTCs) |
| Date: | November 30, 2004 |
| Re: | Addition of Dental Procedure Codes to the Ambulatory Procedures Listing (APL) |
Effective with dates of service on and after January 1, 2005, the department will reimburse hospitals and ASTCs an all-inclusive rate for facility services associated with certain dental procedures performed in the hospital outpatient or ASTC setting.
Specific criteria have been established that must be met in order to justify the medical necessity of performing the procedure in the outpatient hospital or ASTC setting. The medical necessity must be clearly documented in the patient's record.
· The patient requires general anesthesia or conscious sedation.
· The patient has a medical condition that places the patient at an increased surgical risk, such as, but not limited to: cardio-pulmonary disease, congenital anomalies, history of complications associated with anesthesia, such as hyperthermia or allergic reaction, or bleeding diathesis; or
· Patient cannot safely be managed in an office setting because of a behavioral, developmental or mental disorder.
A group of Healthcare Common Procedure Coding System (HCPCS) dental codes will be added to APL Group 1d - Surgical Procedures/Very Low Intensity. These dental codes are the same codes billable by dentists under the department's dental program. The HCPCS dental codes are five-digit codes beginning with a "D" alpha character, and are listed in the attachment to this notice. Please note that some dental codes have age restrictions and are designated for children through age 20 only. If a dental service is non-covered due to the age of the patient, the hospital or ASTC will not be reimbursed the facility fee.
The procedures will be reimbursed at the current rate of $273.00 for hospitals. ASTC reimbursement, as with other APL reimbursement, is set at 75% of the rate for hospitals. If an additional APL procedure(s) is performed on the same day as a dental procedure, payment will continue to be made at the rate of the highest-paying APL procedure.
No prior approval will be necessary, but claims are subject to post-payment review by the department's peer review organization.
The APL will be revised at a later date. The APL is available on the department's Web site at <http://www.dpaillinois.com/reimbursement/apl.html>.
To reduce copying and mailing cost, the department may not always include hardcopies of attachments referenced in notices and bulletins. Web site links will be identified so providers may view and print the material from the Internet. Providers wishing to receive e-mail notification, when new provider information has been posted by the department, may register at the following IDPA Web sites:
http://www.dpaillinois.com/provrel/
Any questions regarding this notice may be directed to the Bureau of Comprehensive Health Services at 877-782-5565 (toll-free) or 217-782-5565.
Anne Marie Murphy, Ph.D.
Administrator
Division of Medical Programs