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13.3.4.11 Dental Anesthesia Provided in an Office Setting
Dental anesthesia is not age restricted.
Procedure codes D9221 and D9242 are not limited to once per day. Procedure code D9242 is limited to two hospital calls or sedation procedures per rolling year for any provider. Procedure code D9221 is not payable unless procedure code D9920 is also paid. Procedure code D9242 is not payable unless procedure code D9241 is also paid.
Procedure code D9248 is a benefit when provided in the office setting for clients of any age. Reimbursement of procedure code D9248 is limited to one service per client per day. Procedure code D9248 is limited to two times per year per client without prior authorization. Any dentist providing nonintravenous (IV) conscious sedation must comply with all Texas State Board of Dental Examiners (TSBDE) Rules and American Academy of Pediatric Dentistry (AAPD) Guidelines, including maintaining a current permit to provide nonIV conscious sedation. Documentation supporting medical necessity and appropriateness for the use of nonIV conscious sedation must be maintained in the client's records and is subject to retrospective review.
Supporting documentation includes, but is not limited to the following:
• The nonIV conscious sedation was provided in full compliance with TSBDE Rules and AAPD Guidelines.
•Narrative addressing why the nonIV conscious sedation was necessary.
•Medications used to provide the nonIV conscious sedation.
•The duration of the nonIV conscious sedation, including the start and end times.
•Monitored statistics, such as vital signs and oxygen saturation levels.
•Any resuscitative measures that may have been necessary.
A provider statement must be included on the claim to indicate that the nonIV conscious sedation was provided in full compliance with TSBDE Rules 108.30-35, 110.1-4, and AAPD Guidelines.
The following procedure codes are denied when billed for the same date of service as procedure code D9248:
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