Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 420.000 - Dental Services › Section 420.453 - Service Descriptions and Limitations: Oral and Maxillofacial Surgery Services Performed by Specialists in Oral Surgery

Current through Register 1525, July 5, 2024
The MassHealth agency pays for oral and maxillofacial surgery
				services subject to the service descriptions and limitations described in 130
				CMR 420.453. Payment for oral and maxillofacial surgery services includes
				routine inpatient preoperative and postoperative care as well as for any
				related administrative or supervisory duties in connection with member
				care.
(A)
Introduction
. Oral and maxillofacial surgery services
			 consist of those basic surgical services essential for the prevention and
			 control of diseases of the oral cavity and supporting structures and for the
			 maintenance of oral health. The MassHealth agency pays for maxillofacial
			 surgery services only for the purpose of anatomic and functional reconstruction
			 of structures that are missing, defective, or deformed because of surgical
			 intervention, trauma, pathology, or developmental or congenital malformations.
			 Cosmetic benefit may result from such surgical services but cannot be the
			 primary reason for those services.
(B)
General
			 Conditions
. The MassHealth agency pays only a dentist who is a
			 specialist in oral surgery for the services listed in Subchapter 6 of the
Dental Manual
designated as Current Procedural Terminology
			 (CPT) codes. Oral and maxillofacial surgery services should be performed in the
			 office location where technically feasible and safe for the member. The
			 MassHealth agency pays for the use of such settings when it is justified by the
			 difficulty of the surgery (for example, four deep bony impactions) and the
			 medical health of the member (for example, asthmatic on multiple medications,
			 history of substance use disorder, seizure disorder, or developmentally
			 disabled). Member fear or apprehension does not justify the use of a hospital
			 or freestanding ambulatory surgery center.
(C)
Surgical
			 Assistants
. The MassHealth agency pays a surgical assistant 15% of
			 the allowable fee for the procedure performed.
(D)
Preoperative Diagnosis and
			 Postoperative Care
. Payment for surgery procedures performed in a
			 hospital or freestanding ambulatory surgery center includes payment for
			 preoperative diagnosis and postoperative care during the member's
			 stay.
(E)
Inpatient
			 Visits
. The MassHealth agency pays providers for visits to
			 hospitalized members, except for routine preoperative and postoperative care to
			 members who have undergone or who are expected to undergo surgery. Inpatient
			 visits are payable only under exceptional circumstances, such as with
			 preoperative or postoperative complications or the need for extended care,
			 prolonged attention, intensive care services, or consultation services. The
			 provider must substantiate the need for this service in the member's hospital
			 medical record.
(F)
Multiple Procedures
. Where two or more individual
			 procedures are performed in the same operative session, the MassHealth agency
			 pays the full amount for the procedure with the highest payment rate, and each
			 additional procedure is payable at 50% of the amount that would have been paid
			 if performed alone. This requires the use of modifiers and applies only to
			 those oral-surgery codes listed in Subchapter 6 of the
Dental
			 Manual
designated as Current Procedural Terminology (CPT)
			 codes.
(G)
Orthognathic
			 Surgery
.
(1) The MassHealth
			 agency pays for orthognathic surgery, including select surgical procedures
			 related to Temporomandibular Joint Disorder or Obstructive Sleep
			 Apnea.
(2) Any proposed
			 orthognathic or orthodontic treatment must meet all the criteria described at
			 130 CMR
			 420.431.