Attention: All Ambulatory Surgical Centers and Dental Providers Billing for Dental Facility Charges by an Ambulatory Surgical Center (ASC)

The Ambulatory Surgical Center (ASC) must submit claims for dental facility use with an electronic claim in NCTracks. Paper claims are no longer accepted. These claims are priced based on total time for the case using one of the following groups:

ASC Group
Total Time
Reimbursement
1
Up to 30 minutes
$307.50
2
31–60 minutes
$411.85
3
61–90 minutes
$470.95
4
Over 90 minutes
$581.76
Providers must complete the claim as instructed below:
a.     Enter the place of service code as “24” for the Ambulatory Surgical Center.
b.    Enter the dental procedure codes (Code on Dental Procedures and Nomenclature CDT-2015) for the services provided by the dentist.
Note: All dental codes begin with the “D” prefix. Only the dental procedure codes (CDT-2015) listed in the Clinical Coverage Policy 4A Dental Services Subsection 5.3, Limitations or Requirements are valid for billing in ASC cases.
c.     Enter modifier SG for each procedure code.
d.    Enter all charges on detail line 1 of the claim.
e.     Enter the total operating room time in units on detail line 1 of the claim (1 unit = 1 minute).
f.     For all remaining detail lines, enter the number of times (units) each dental procedure was provided with zero charges.
g.    Submit all dental procedure codes on one electronic claim for the surgery date.