Anesthesia for Dental Cases: Considering All the Angles

Summary

Is dental anesthesia a service anesthesia practices should be more focused on? Probably not, as it tends to be a small part of most group practices. Still, as some practices have discovered, it can provide some additional revenue.

Periodically, we are asked by our clients if they should be more aggressively pursuing dental opportunities. Is dental anesthesia an untapped opportunity? As in so many anesthesia practice management questions, the answer is it depends on three critical factors, which we refer to as logistical, financial and strategic.

Looking at the Logistics

From a logistical perspective, the administration of anesthesia in a dental office or clinic poses many of the same challenges as any office-based anesthesia service. The office or facility must meet certain minimum requirements for monitoring, anesthesia agents and the ability to recover patients appropriately. Some clients have had to purchase anesthesia machines or glidescopes that they literally transport to the site for administration of the anesthetic. This often represents a cost that must be borne by the anesthesia practice. Not all drugs or consumables can be billed to the patient or the patient's insurance.

There is also the scheduling consideration. A full day of cases in a single location is always ideal, but not always the reality. This is a fundamental challenge for all ambulatory anesthesia. The more locations that must be covered, the more the practice must invest in scheduling and deployment tools. Ultimately, this raises the question as to whether the practice has assigned dedicated staff to cover the ambulatory facilities or whether these are viewed as supplemental cases for those who are interested in pursuing them. In some practices, physicians may opt to do these cases on post-call days for additional compensation.

Fundamentally, if an anesthesia practice commits to providing an ambulatory anesthesia service, it must be prepared to do so irrespective of the consistency or profitability of each day's work. It is the rare ambulatory opportunity that does not experience significant variability in volume and payer mix from day to day. What looks like a great revenue opportunity on the front-end may not prove to be so profitable over time.

Focusing on the Financials

The financial question is always the key. Will the practice get paid for dental anesthesia? A review of data for a select group of ABC clients across the country reveals surprisingly positive results. Most payers do seem to recognize and pay for dental anesthesia, but there are some caveats, and policies definitely vary by plan. For example, some payers require not only a pre-authorization from the dental provider/oral surgeon, but a separate one covering the anesthesia. Often both can be secured by the dental provider at the same time. To the extent you can, make sure this authorization has been obtained, where required, prior to the procedure.

Billing for anesthesia for a surgical procedure is usually quite simple. The CPT code for the surgical procedure is mapped to the corresponding ASA code to determine the base value. This, plus the time units, determines the charge and is the basis for payment. Dental cases, on the other hand, pose some specific challenges. First, the CPT code for dental procedures is an unlisted, meaning non-specific, code: 41899. This maps to a code for intraoral procedures: 00170, a code that includes a variety of procedures, such as tonsillectomies. Dental billing relies on a separate coding sequence referred to as "the D-codes," which some plans require for dental anesthesia.

Medical necessity may also play a factor in payer adjudication. In other words, there must be a clinical justification for the services of an anesthesiologist or CRNA. This criterion often means that services provided to normal, healthy adults are denied. Pediatric cases are generally covered; but, depending on the insurance, the payment amounts may be based on Medicaid rates. In other words, there must be a reasonable clinical justification for the service and the charge. Accordingly, the medical necessity for the service must be clearly documented on the chart.

The typical dental case is worth about 10 ASA units (five base units and five time units). When paid, they are typically reimbursed at rates comparable to those for all other anesthesia services. We did not note any unusual denial patterns in our review of billing for the six practices in the sample. An average Medicare payment is about $270. Commercial insurance rates can be two or three times that amount. Clearly, though, the most profitable arrangements were those involving cash payments, which have been negotiated by a number of clients for some of their key dental clients.

Stressing the Strategic

Anesthesia practices look for expansion opportunities for a variety of reasons. Some are purely financial but most are strategic. The financial opportunities exist when there are profitable cases that can easily be covered with existing staff. Such opportunities are usually relatively rare and may have very limited growth potential. It is more common for groups to look at expansion as a way of diversifying the practice or garnering market share. From this perspective, dental cases are not likely to be all that useful. To put it plainly, getting a contract for anesthesia at a dental practice is not likely to open up any significant markets for the practice.