14.2.6.3 Dental General Anesthesia Provided in the Inpatient or Outpatient Setting (Medically Necessary Dental Rehabilitation or Restoration Services)

Dental rehabilitation or restoration services requiring general anesthesia may be performed in the inpatient or outpatient setting.

CSHCN Services Program dental services should be billed using the following Current Procedural Terminology (CPT) procedure codes and modifier where appropriate:

•	Anesthesia services for dental rehabilitation or restoration and general dental anesthesia, procedure code 00170 with modifier U3

•	ASC or HASC dental rehabilitation or restoration, procedure code 41899 with modifier U3

•	Physical examinations before dental restorations under anesthesia, procedure codes 99202, 99222, and 99282

•	Restorations under anesthesia, procedure codes 99222 and 99282

Prior authorization is not required for the use of general anesthesia while rendering treatment (to include the dental service fee, the anesthesia fee and facility fee), regardless of place of service. Supporting documentation must be retained in the client’s chart and must reflect compliance with the “CSHCN Services Program Criteria for Dental Therapy Under General Anesthesia” form. Dental general anesthesia may be reimbursed once every 6 months per client per provider.

All supporting documentation must be maintained in the client’s medical record. The client’s record must be available for review by representatives of the CSHCN Services Program, the Department of State Health Services (DSHS), the CSHCN Services Program claims contractor, and HHSC. The dental provider is required to maintain the following documentation in the client’s dental record:

•	The medical evaluation justifying the need for anesthesia

•	Description of relevant behavior and reference scale

•	Other relevant narrative justifying the need for general anesthesia

•	Client’s demographics, including date of birth

•	Relevant dental and medical history

•	Dental radiographs, intraora or perioral photography, or diagram of dental pathology

•	Proposed dental plan of care

•	Consent signed by parent or guardian giving permission for the proposed dental treatment and acknowledging that the reason for the use of IV sedation or general anesthesia for dental care has been explained

•	Completed “CSHCN Services Program Criteria for Dental Therapy Under General Anesthesia” form

•	The parent or guardian dated signature on the Criteria for Dental Therapy Under General Anesthesia form attesting that the parent or guardian understands and agrees with the dentist’s assessment of their child’s behavior

•	Dentist’s attestation statement and signature, which is put on the bottom of the CSHCN Services Program Criteria for Dental Therapy Under General Anesthesia form or included in the record as a separate form

Hospital and outpatient facility admissions are subject to medical necessity review.

Refer to:

Appendix B, “CSHCN Services Program Criteria for Dental Therapy Under General Anesthesia,” on page B‑111.