130 CMR, § 420.453

Current through Register 1536, December 6, 2024

Section 420.453 - Service Descriptions and Limitations: Oral and Maxillofacial Surgery Services Performed by Specialists in Oral Surgery

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.