September 11, 2023

VIA ELECTRONIC SUBMISSION
The Honorable Chiquita Brooks-LaSure
Administrator
Centers for Medicare and Medicaid Services
Department of Health and Human Services
Attn: CMS-1786-P
P.O. Box 8010
Baltimore, MD 21244-1810
Re:

Comments on CY 2024 Medicare Hospital Outpatient Prospective Payment System andAmbulatory Surgical Center Payment System Proposed Rule (“HOPPS/ASC Proposed Rule” or“Proposed Rule”)

Dear Administrator Brooks-LaSure:On behalf of the members of the American Academy of Pediatric Dentistry (AAPD), American Dental
Association (ADA) and the American Association of Oral and Maxillofacial Surgeons (AAOMS), we are
writing to you to provide our comments on the 2024 HOPPS/ASC Proposed Rule.
We very much appreciate CMS’ responsiveness to our concerns about access to hospital and ASC
Operating Rooms (ORs) for those of our patients whose dental procedures must be provided undermonitored anesthesia. Last year’s decision by CMS to adopt a new HCPCS code for dental rehabilitation(G0330) and to increase the Ambulatory Payment Classification (APC) rate for these procedures has
begun to significantly help us to address the lack of OR access for dental cases. In this context, we thank
CMS for following up on last year’s action by including in the Proposed Rule a provision that would
include dental rehabilitation (HCPCS G0330) on the ASC Covered Procedures List (CPL). Finalizing this
proposal has the potential to make ASC ORs available not only for our Medicare patients but also for
Medicaid and other patients whose third-party payers utilize the CPL to determine which procedures are
eligible for ASC coverage.
At the same time, we believe that the inadequacy of the proposed payment rates for dental
rehabilitation in both the hospital and the ASC settings is likely to stymie use of the dental rehabilitation
code to increase OR access for our patients. We also believe that CMS’ approach to coverage andpayment for other dental services under HOPPS and under the ASC payment system is confusing and islikely to increase administrative burden unless changes are made to reconcile the two payment systems.

{D1076733.DOCX / 1 }Proposed CY 2024 HOPPS-ASC Rule
Comments by AAPD, ADA and AAOMSPage 2
Summarizing, our recommendations are as follows:
Recommendations (Dental Rehabilitation): We recommend that CMS reclassify dental
rehabilitation (G0330) into the Level 4 ENT comprehensive APC (APC 5164); establish Medicare
payment for dental rehabilitation performed in ASCs using the payment weight and conversion
factor applicable to Category 4 ENT Procedures (APC 5164); and either clarify or refrain fromfinalizing the proposal to require that dental rehabilitation be billed with a non-payable ancillary
service in order for the dental rehabilitation to be covered.
Recommendations (Other Dental Procedures): We recommend that CMS reconcile the HOPPS
and APC payment systems by including on the ASC CPL all dental services that are classified into
APCs under HOPPS, with the exception of imaging and evaluation and management dental
services, which should be included on the ASC Ancillary Services List.
I.

Preliminary Observations and Requests

Preliminarily, we wish to request clarification of a principal issue posed by the Proposed Rule. Last year,
in addition to adding a specific new HCPCS code (G0330) and providing increased payment for dental
rehabilitation, CMS expanded Medicare coverage to include dental services that are inextricably linked
to, and substantially related and integral to the clinical success of, particular Medicare-covered services.
The 2024 Physician Fee Schedule (PFS) Proposed Rule proposes to expand Medicare coverage for dental
services further, and CMS is continuing to solicit recommendations for additional dental coverage
expansion.
We appreciate CMS’ recognition that some newly covered dental services may be performed in hospitaland ASC settings and to include in the HOPPS/ASC Proposed Rule an extensive proposal to add new
dental codes (CDT) to HOPPS and to the ASC payment system. However, it is unclear to us whether, andunder what circumstances, dental rehabilitation (G0330) can or should be billed with individual dental
procedures (“D” codes) proposed for HOPPS/ASC payment. It is unclear to us whether a hospital or ASC
that makes its OR available for the performance of dental procedures under monitored anesthesia:••••

May opt to bill for its facility services either using G0330 (dental rehabilitation) or using
individual “D” codes payable under the HOPPS or ASC facility payment system;
Must bill only for the individual “D” codes if one or more of the procedures performed is payable
under HOPPS or under the ASC payment system;
Must bill only for dental rehabilitation (G0330) if multiple procedures are performed; orMay bill for any “D” codes that are performed and that are separately billable and, in addition,
may bill for dental rehabilitation (G0330) for procedures that are not separately payable.

We are concerned that, in the absence of clarification in the 2024 HOPPS Final Rule, hospitals and ASCs
may be extremely confused regarding whether and under what circumstances they should report dental
rehabilitation (G0330), CDT codes, or both for payment.
Recommendation: We strongly recommend that the 2024 HOPPS Final Rule clarify whether andunder what circumstances dental rehabilitation (G0330) should be reported in addition to or inlieu of CDT codes, under HOPPS and under the ASC payment system.

{D1076733.DOCX / 1 }Proposed CY 2024 HOPPS-ASC Rule
Comments by AAPD, ADA and AAOMSPage 3II.

Dental Rehabilitation

CMS’ decision last year to establish a new HCPCS code for dental rehabilitation (G0330) and to assign thisHCPCS code to a higher-paying APC was a significant step forward in making dental care accessible fordisabled and other Medicare patients whose dental care may require OR facilities. In addition, CMS’
action has had a positive impact on Medicaid plans’ payment for the facility services associated withdental procedures requiring monitored anesthesia. As the result of CMS’ 2023 HOPPS Final Rule anddentist engagement at the state level, several State Medicaid Agencies (SMAs) have increased payment
for dental procedures performed for Medicaid patients in hospital settings or have made facility
payments available for dental services for the first time. Our organizations are continuing to collect dataon Medicaid payment changes and the impact of these changes on OR access for Medicaid patients inneed of dental rehabilitation -- many of whom are children.
We anticipate that CMS’ inclusion of dental rehabilitation (G0330) on the ASC CPL has the potential tofurther increase access to safe operating room settings for Medicare patients enrolled in Medicare
Advantage (MA) plans, Medicaid, and commercial insurance as well. The CPL is widely used by nonMedicare payers and MA plans, and we believe that the inclusion of dental rehabilitation on the ASC CPL
will encourage state Medicaid agencies to include dental rehabilitation as a covered service in ASC
settings.
Recommendation (Non-Medicare Payment): We urge CMS to make clear in the Final Rulepreamble that because Medicare’s coverage of dental procedures remains limited, the exclusionof a particular procedure from the HOPPS or from the CPL does not suggest that facility payment
should be disallowed by other payers.
A.

Dental Rehabilitation (G0330) Should Be Reclassified into the Level 4 ENT APC (APC
5164)

Based on our analysis of the cost statistics made available with the Proposed Rule, we believe that thesignificant proposed reduction in the APC payment for dental rehabilitation provided in the hospital
outpatient setting may result from hospitals’ billing a wider range of lower cost CDT codes during thetwo-year base period for the CY 2024 Proposed APC rate than during the base period for the 2023 rate.
As the result of the submission of a broader range of claims for dental procedures, the hospital
outpatient claims included in the calculation of the APC rate for APC 5871, which currently includes
dental rehabilitation, is extraordinarily broad, ranging from a geometric mean cost of $17.75 to ageometric mean cost of $7,883.25. See Attachment A.
The payment reduction resulting from hospitals’ submission of more lower cost dental claims is
exacerbated by CMS’ proposal to apply the multiple procedure reduction to dental rehabilitation(G0330). As indicated in our comments on the 2023 Proposed Rule and in multiple meetings with CMS
over the last several years, dental rehabilitation involves extensive, multiple procedures performed forpatients that require monitored anesthesia due to the extraordinary amount of dental surgical work thatneeds to be provided, the patient’s youth, disability, or medical condition, or other factors.

{D1076733.DOCX / 1 }Proposed CY 2024 HOPPS-ASC Rule
Comments by AAPD, ADA and AAOMSPage 4
Recommendation (Multiple Procedure Reduction): Since the dental rehabilitation code is used
to report the performance of multiple procedures that otherwise would be separately billable, it
is entirely inappropriate to apply the multiple surgical procedure discount to hospital dental
rehabilitation claims.
We believe that finalizing the Proposed Rule’s precipitous drop in the Medicare payment rate associatedwith dental rehabilitation in the hospital outpatient setting and the Proposed Rule’s establishment of aclearly inadequate ASC payment rate will halt and may potentially reverse the progress that has been
made in expanding OR access for dental cases. If finalized without change, the APC rate for these
services would drop from $1,722.43 in 2023 to $938.69, a reduction of over 45%. Under the Proposed
Rule, the national average ASC payment for these services would be only $495.52. This devastating drop
in hospital outpatient payment for dental rehabilitation and the establishment of a clearly inadequate
ASC rate threatens to dissuade both hospitals and ASCs from making their facilities available to address
the continuing unmet need for well-equipped ORs for our patients.
More specifically, we urge CMS to reclassify dental rehabilitation (G0330) into APC 5164. This APC
reclassification is consistent with the available cost and charge data for dental procedures likely to bereported as dental rehabilitation using HCPCS G0330. Prior to the adoption of a specific HCPCS code toreport dental rehabilitation, these procedures were reported using the CPT code for miscellaneous
dental procedures (CPT 41899), whose geometric mean costs for the 2024 HOPPS base period are$2261.99, well within the range of geometric mean costs of other procedures classified into the Level 4
ENT APC. See Attachment B. Moreover, our analyses suggest that the APC rate for APC 5164 is consistent
with the amounts that would be paid if the individual procedures generally involved in dental
rehabilitation were billed separately. Therefore, reassigning HCPCS G0330 to APC 5164 is consistent withthe mandate of the governing statute, which requires that procedures in the same APC be comparable interms of resource use.
Recommendation (Reclassification of Dental Rehabilitation into APC 5164): CMS should
reclassify dental rehabilitation (G0330) into APC 5164 based on available cost data and payment
amounts for comparable procedures.
B. CMS Should Not Finalize the Proposed Special Billing Requirements for Dental
Rehabilitation Performed in an ASC Setting
We very much appreciate and support CMS’ proposal to add dental rehabilitation to the ASC CPL. Dental
rehabilitation meets the criteria for inclusion on the CPL1, since dental rehabilitation procedures areprocedures that:
•
•
•

1

Are separately paid under the OPPS;
Would not be expected to pose a significant safety risk to a Medicare beneficiary when
performed in an ASC; andFor which standard medical practice dictates that the beneficiary would not typically be
expected to require active medical monitoring and care at midnight following the procedure.

42 CFR §416.166(b).

{D1076733.DOCX / 1 }Proposed CY 2024 HOPPS-ASC Rule
Comments by AAPD, ADA and AAOMSPage 5
Surgical procedures that meet these requirements and that are not explicitly excluded from coverage
are eligible of inclusion on the ASC CPL. Dental rehabilitation does not meet any of the exclusion criteria:
These procedures do not pose a risk of significant blood loss, do not involve major or prolonged invasionof body cavities, do not directly involve major blood vessels, are not generally emergent of life
threatening in nature, do not require systemic thrombolytic therapy, and are not designated as requiring
inpatient care, all of which are grounds for exclusion of a procedure from the ASC CPL.2
Since it is clear that dental rehabilitation meets the regulatory criteria for inclusion on the CPL, we are
puzzled by CMS’ proposed requirement that, to be covered by Medicare, dental rehabilitation (G0330)
be billed along with a covered but non-payable dental ancillary service. We simply do not understandwhat purpose is served by this requirement. We are hopeful that clarity regarding circumstances underwhich dental rehabilitation (G0330) should be reported in addition to or in lieu of CDT codes, under
HOPPS and under the ASC payment system would help us better under the purpose of requiring acovered ancillary service to be billed for dental rehabilitation to be covered.
To the extent that CMS is proposing to impose this requirement to ensure patient safety, we believethat the proposal is misguided. As indicated in our prior discussions with and submissions to CMS, dental
rehabilitation involves dental procedures that ordinarily would be performed in a dentist’s office, but for
the need to administer monitored anesthesia to address the patient’s particular age, clinical,
psychological, or other needs. In fact, since dental rehabilitation is comprised entirely of procedures
performed in dentists’ offices for most patients, it is difficult for us to understand what safety
considerations would limit the performance of these services in a much more highly regulated ASC
setting that is required to meet extensive Medicare and state licensure requirements. According to the
Ambulatory Surgery Center Association (ASCA), dental procedures (previously reported using HCPCS
41899) were performed 71,686 times on non-Medicare patients in 492 CMS-certified ASCs that perform
dental surgery, apparently without significant incident. Moreover, if there were special safety concerns
applicable to dental rehabilitation procedures (which there are not), it is difficult to see how thecontemporaneous provision of a non-payable ancillary service would address those concerns.
Recommendation (Special Billing Requirement for Dental Rehabilitation): We recommend thatCMS clarify why a covered ancillary service must be billed with dental rehabilitation for dental
rehabilitation to be covered or, alternatively, refrain from finalizing this requirement in the 2024
PFS Final Rule.
III.

Alignment between HOPPS and ASC Dental Procedures
A. CMS Should Conform Medicare Payment for Dental Procedures Performed in ASCs
to Payment for Dental Procedures Performed in Hospital Outpatient Settings

CMS proposes to classify 229 dental procedures into APCs for HOPPS payment, but to include only 26
dental procedures on the ASC CPL. The criteria for determining which procedures are proposed forinclusion on the ASC CPL are not described in the Proposed Rule.

2

42 CFR §416.166(c).

{D1076733.DOCX / 1 }Proposed CY 2024 HOPPS-ASC Rule
Comments by AAPD, ADA and AAOMSPage 6
We can think of only two rationales for excluding a dental procedure that is payable under HOPPS fromthe ASC CPL. First, a dental procedure might be excluded from the ASC CPL if it were unsafe to provide in
an ASC setting. However, all dental procedures meet the regulatory criteria for inclusion on the ASC list
and dental procedures have been and continue to be performed in ASC settings without raising safetyconcerns. In fact, all of the 229 dental procedures eligible for HOPPS payment are routinely provided in
dentists’ offices, which are less regulated environments that are subject to neither state licensure nor
Medicare certification requirements. The primary safety issues involved relate to unavoidable anesthesia
risks, which ASCs are well equipped to handle.
Second, under the current proposal, a dental procedure for which a facility fee is payable under HOPPS
might be excluded from the ASC CPL. However, for the purposes of inclusion on the ASC CPL, our groups
advise that all surgical procedures – including most dental procedures involving hard or soft tissue should be payable in both settings. The AMA defines “surgery” broadly to include procedures“performed for the purpose of structurally altering the human body by the incision or destruction oftissues…” including:the diagnostic or therapeutic treatment of conditions or disease processes by any instruments
causing localized alteration or transposition of live human tissue which include lasers, ultrasound,ionizing radiation, scalpels, probes, and needles. The tissue can be cut, burned, vaporized, frozen,
sutured, probed, or manipulated by closed reductions for major dislocations or fractures, orotherwise altered by mechanical, thermal, light-based, electromagnetic, or chemical means.
Injection of diagnostic or therapeutic substances into body cavities, internal organs, joints, sensory
organs, and the central nervous system.3
Moreover, while the Medicare regulations no longer include the prior regulatory definition of surgicalprocedure, it is relevant that Medicare regulations previously defined a surgical procedure as “one that
requires a dedicated operating room (or suite), and generally requires a post-operative recovery room or
short-term (not overnight) convalescent room.”4 Under this definition, all dental procedures performed
in an OR setting that require convalescence should be considered “surgical” for ASC CPL purposes.
We also note that CMS itself appears to recognize that many dental procedures not included on the ASC
CPL are surgical procedures. Many procedures not included on the ASC CPL are designated with statusindicator “T” for HOPPS payment purposes, indicating that the procedure is subject to the Multiple
Procedure Reduction, a payment reduction applicable only to diagnostic and certain surgical procedures.
Recommendation (ASC CPL): We urge CMS to include all dental procedures payable under
HOPPS on the ASC CPL, with the exception of imaging and dental evaluation services, whichshould be included on the ASC “Ancillary Services” List. We also urge CMS to include D1120(dental prophylaxis – child) on the Ancillary Services List, to accompany D1110 (dental
prophylaxis – adult) for services across the lifespan.

3

AMA Definition of Surgery. H-475.983; https://policysearch.amaassn.org/policyfinder/detail/surgery?uri=%2FAMADoc%2FHOD.xml-0-4317.xml.
442 CFR §416.65((a)(3) (applicable prior to January 1, 2022).

{D1076733.DOCX / 1 }Proposed CY 2024 HOPPS-ASC Rule
Comments by AAPD, ADA and AAOMSPage 7V.

Future Challenges

We look forward to continuing to work with CMS to address coding and payment structures to ensure
facility payment for dental services under appropriately priced APCs that reflect the facility resources
involved for these services, and to authorize the same code set to be paid in both hospital outpatientand ASC settings. The establishment of the new HCPCS code G0330 for dental rehabilitation and theclassification of this code into the Level 4 ENT APC provides a useful paradigm for the establishment ofappropriate comprehensive APCs for dental cases.
We would further reiterate that the need for a hospital or ASC setting for the performance of dental
services often is not dictated by the nature of the procedure itself but rather the unique characteristicsof the patient involved.
We appreciate that CMS will continue to assess Medicare coverage and payment policies for dental
services under HOPPS and under the ASC payment system in future rulemaking. We anticipate thatclaims data will be critical in future rate setting. We are concerned that inadequate payment rates andother coverage restrictions reflected in the Proposed Rule flagged in this letter and our individuallysubmitted organization comment letters may not only significantly limit the extent to which hospital andASC settings are made available to the patients collectively cared for by our members but also severely
limit the availability of claims data for CMS’ and our future analysis.
We appreciate the opportunity to comment on the Proposed Rule. If you have any questions, please do
not hesitate to contact Julie Allen at Julie.Allen@PowersLaw.com.
Sincerely yours,

Scott Cashion, D.D.S, M.S.
President
American Academy of
Pediatric Dentistry{D1076733.DOCX / 1 }Paul J Schwartz, D.M.D
President
American Association of Oraland Maxillofacial SurgeonsGeorge R. Shepley, D.D.S.
President
American Dental Association

Proposed CY 2024 HOPPS-ASC Rule
Comments by AAPD, ADA and AAOMSPage 8
Attachment A

HCPCSSingleFrequency

Total
Frequency

Median
Cost

Geometric
Mean Cost

D2910
D2920
D2932
D2954
D2950
D3220
D2331
D4342
D4910
D3320
D3310
D2330
D2940
D3221
D2740
D2332
D2751
D7473
D4341
D2335
D7111
D3330
D2150
D2710
D7220
D7250
D2391
D7210
D2392
D7472
D2140
D2160
D7140
D4346

1
5
3
2
6
2
5
6
7
1
2
7
8
4
8
6
2
2
13
6
1
2
3
4
2
1
13
28
7
3
6
1
36
1

1
7
10
2
6
3
90
26
11
1
4
117
12
4
11
59
2
9
166
60
1
2
72
5
10
8
163
233
97
3
64
32
338
4

$17.75$30.14$57.10$114.40$104.60$129.41$109.17$102.59$189.00$267.08$326.43$126.98$848.54$767.78$465.91$349.64$502.46$529.28$1,604.48$691.31$676.03$686.08$1,795.18$1,632.54$1,817.08$2,362.80$2,845.88$2,629.75$2,659.86$2,163.98$2,567.60$2,692.34$2,578.45$3,478.76$17.75$41.79$57.10$94.08$98.90$129.16$130.54$231.91$248.09$267.08$309.46$313.83$337.82$437.65$462.90$490.49$502.46$529.28$535.63$668.51$676.03$686.08$934.53$1,070.06$1,800.95$2,362.80$2,455.60$2,498.43$2,606.62$2,652.60$2,671.63$2,692.34$2,716.69$3,478.76{D1076733.DOCX / 1 }Proposed CY 2024 HOPPS-ASC Rule
Comments by AAPD, ADA and AAOMSPage 9
D4355
D7240
D2393
D7230
D2161

2
11
1
2
1

10
38
44
10
6

$3,549.99$2,902.39$4,181.47$7,493.39$7,883.25$3,495.77$3,502.89$4,181.47$7,387.89$7,883.25

Procedures in red were also performed during the base period for the current APC rates.

{D1076733.DOCX / 1 }Proposed CY 2024 HOPPS-ASC Rule
Comments by AAPD, ADA and AAOMSPage 10
Attachment B

41110

Excision of tongue lesion

5164

41112

Excision of tongue lesion

5164

41113

Excision of tongue lesion

5164

41899 Misc Dental

5161

41114

Excision of tongue lesion

5164

41116

5164

41820

Excision of mouth lesion
Reconstruction tongue
foldTongue base vol
reduction
Excision gum eachquadrant

41825

Excision of gum lesion

5164

41826

Excision of gum lesion

5164

41830

Removal of gum tissue

5164

41872

Repair gum

5164

41874

Repair tooth socket
Excision lesion mouth
roof
Excision lesion mouth
roof

5164

Excision of uvula
Treatment mouth roof
lesionDrainage of salivary
gland
Removal of salivarystoneRemoval of salivary
stone

5164

41520
41530

42104
42106
42140
42160
42305
42330
42335

{D1076733.DOCX / 1 }

5164
5164
5164

5164
5164

5164
5164
5164
5164

$
3,087.88$
3,087.88$
3,087.88$
233.00$3,087.88$
3,087.88$
3,087.88$
3,087.88$
3,087.88$
3,087.88$
3,087.88$
3,087.88$
3,087.88$
3,087.88$
3,087.88$
3,087.88$
3,087.88$
3,087.88$
3,087.88$
3,087.88$
3,087.88$
1,931.74$
2,062.44$
2,122.72$
2,261.99$
2,338.54$
2,442.92$
2,459.42$
2,535.50$
2,535.99$
2,602.28$
2,619.31$
2,655.23$
2,680.51$
2,748.77$
2,812.80$
2,829.75$
2,848.20$
2,935.72$
3,022.23$
3,023.55$
3,026.20

Proposed CY 2024 HOPPS-ASC Rule
Comments by AAPD, ADA and AAOMSPage 11

42340

Removal of salivary
stone

5164

42408

Excision of salivary cyst

5164

42409

Drainage of salivary cyst

5164

42510

Parotid duct diversion
Closure of salivary
fistula

5164

5164

42806

Ligation of salivary duct
Drainage of throat
abscess
Biopsy of upper
nose/throat
Biopsy of upper
nose/throat

42808

Excise pharynx lesion

5164

42810

5164

42821

Excision of neck cyst
Remove tonsils andadenoids

42826

Removal of tonsils

5164

42830

Removal of adenoids

5164

42831

Removal of adenoids

5164

42836

Removal of adenoids

5164

42860

Excision of tonsil tags

5164

42962

Control throat bleeding
Control nose/throat
bleeding

5164

42600
42665
42720
42804

42972

{D1076733.DOCX / 1 }

5164

5164
5164
5164

5164

5164

$
3,087.88$
3,087.88$
3,087.88$
3,087.88$
3,087.88$
3,087.88$
3,087.88$
3,087.88$
3,087.88$
3,087.88$
3,087.88$
3,087.88$
3,087.88$
3,087.88$
3,087.88$
3,087.88$
3,087.88$
3,087.88$
3,087.88$
3,056.06$
3,097.92$
3,135.42$
3,231.30$
3,254.46$
3,361.42$
3,373.45$
3,392.82$
3,415.22$
3,498.38$
3,543.25$
3,553.89$
3,577.91$
3,578.78$
3,591.48$
3,817.06$
3,917.32$
4,087.37