New Procedure Code for Facility Services for Dental Rehabilitation Cases in an Ambulatory Surgical Center

Annual update effective Jan. 1, 2023

Effective with date of service Jan. 1, 2023, the following HCPCS procedure code will be added for NC Medicaid. This addition is a result of the annual HCPCS code updates. Clinical Coverage Policy 4A, Dental Services will be updated to reflect these changes.

New HCPCS Code: G0330

Short Description: Facility Services Dental Rehab

Long Description: Facility services for dental rehabilitation procedure(s) performed on a patient who requires monitored anesthesia (e.g., general, intravenous sedation (monitored anesthesia care) and use of an operating room)

Ambulatory Surgical Center Dental Operating Room Facility Time: G0330

For beneficiaries covered under NC Medicaid Direct (billed in NCTracks) or an NC Medicaid Managed Care Prepaid Health Plan (PHP), the Ambulatory Surgical Center (ASC) must submit claims for dental operating room facility time with the new HCPCS procedure code G0330 effective Jan. 1, 2023.

Providers must complete the claim as instructed below:

1. Enter information on an electronic Professional CMS-1500 claim (paper claims are not accepted).
2. Enter the place of service code as “24” for the ASC.
3. Enter HCPCS procedure code “G0330” for facility use when dental treatment is rendered in the ambulatory surgical center.
4. Enter modifier “SG” with the procedure code.
5. Enter the total of all usual and customary facility charges on detail line 1 of the claim.
6. Enter the total operating room time on detail line 1 of the claim (one unit = one minute).

These claims will be reimbursed based on the total time for each case, as follows:

Providers are reminded to bill their usual and customary charges rather than the Medicaid rate. For coverage criteria and additional billing guidelines, please refer to Clinical Coverage Policy 4A, Dental Services on the NC Medicaid Clinical Coverage Policies website.

Contact

NC Medicaid Dental Program, 919-855-4280