Welcome to the blog

Whether to bill for local anesthesia in conjunction with dental procedures requires careful consideration, particularly in light of coding guidelines and payer policies. Understanding the nuances of the CDT (Current Dental Terminology) language, ethical billing practices, and payer requirements is essential for maintaining compliance and avoiding potential issues.

CDT Language – Local Anesthesia Billing

Every code set used in healthcare to document dental and medical procedures and diagnoses contains guidelines that must be followed to ensure an accurate population of the patient’s health records and ethical and compliant billing practices. One such guideline of CDT is reporting local anesthesia as a separate procedure in addition to the dental procedure rendered. A guideline found at the beginning of the Restorative category states, “Local anesthesia is usually considered to be part of Restorative procedure.” This language regarding local anesthesia is also found in the following categories: Endodontics, Periodontics, Prosthodontics (Removable), Implant Services, Prosthodontics, fixed, and Oral & Maxillofacial Surgery.  

This term, “usually,” serves as a coding guideline and underscores that there are instances where billing for anesthesia may be appropriate. However, routine billing for local anesthesia in all circumstances does not align with coding guidelines or best billing practices and can raise compliance concerns.

To determine whether billing for anesthesia is justified, one must review applicable payer policies carefully. Insurance plans typically consider local anesthesia inclusive and integral to the procedure. Thus, submitting anesthesia as a separate billing item in such cases could be inappropriate. Dental professionals are encouraged to thoroughly assess the circumstances under which they believe billing for anesthesia is warranted and clearly document the reasons.

When Billing for Local Anesthesia May Be Appropriate

While most routine procedures, such as fillings, do not warrant separate billing for local anesthesia, there are exceptions where it may be appropriate and justified. For example:

A patient presents with significant decay requiring operative treatment. During excavation, it is discovered that the tooth is fractured, or the pulp is exposed. The dentist administers a long-acting anesthetic to manage the pain and ensure patient comfort until they can visit a specialist later the same day.

Another scenario involves emergency cases where pain control is necessary:

A patient arrives at the dental office in severe pain, requiring immediate attention. The treating dentist administers local anesthesia to numb the affected area for pain relief. This intervention can serve two purposes— to stabilize the patient until they can be referred to a specialist or to assist in the diagnostic process by allowing a thorough examination without the hindrance of acute discomfort.

These examples highlight situations that go beyond routine care, where the administration of local anesthesia is clinically justified. The key here is clear documentation—detailing both the condition of the tooth or the patient’s situation and the reasoning for additional anesthetic administration under these exceptional circumstances.

There are two available CDT codes to consider when the treating provider determines that billing for local anesthesia is appropriate for a particular patient and is specific to their documented condition and circumstance. The codes are:

D9210 local anesthesia not in conjunction with operative or surgical procedures

D9215 local anesthesia in conjunction with operative or surgical procedures

Why Routine Billing for Anesthesia Is Problematic

Routinely billing for local anesthesia in cases where it is typically included as part of the procedure carries several risks:

1. Non-Compliance with Payer Policies
   If an insurance plan explicitly states that local anesthesia is inclusive, submitting anesthesia as a separate procedure could result in billing discrepancies or even allegations of improper billing practices.
2. Audits and Potential Consequences
   Improper billing increases the likelihood of payer audits, which can uncover patterns of routine claims inconsistent with the plan’s provision. This scrutiny could lead to claim denials, repayment demands, or more serious actions.
3. Professional Integrity
   Ethical billing practices are foundational to maintaining trust and professionalism in the dental field. Routinely billing for services typically included in the code and fee erodes that trust and risks reputational harm.

Best Practices for Billing Local Anesthesia

To ensure compliance and align with ethical practices, consider the following recommendations:

• Know Your Payer Policies: Invest time in understanding the specific requirements of the insurance carriers you work with. If in doubt, contact the payer for clarification.
• Document Thoroughly: When billing for local anesthesia separately, provide detailed clinical notes justifying its necessity. Include information on the patient’s condition and why administering additional anesthesia was required.
• Avoid Routine Billing: Establish clear internal policies discouraging routine billing for anesthesia when it is typically included as part of the procedure. Educate your staff to identify and report situations where billing may apply.
• Align with CDT Guidelines: Follow CDT language precisely, which specifies that anesthesia is “usually” considered inclusive but allows for flexibility when circumstances diverge from the norm.

Final Thoughts

Billing for local anesthesia separately from dental procedures must be approached with care, professionalism, and adherence to established guidelines. While there are specific situations where it is appropriate to bill for anesthesia, such instances are exceptions—not the rule. Understanding coding guidelines, payer policies, and documenting the clinical necessity of services are critical steps to ensure ethical and compliant billing practices. Adopting a cautious and precise approach to billing benefits the dental practice and the trust and care patients place in their providers.

Disclaimers:

The information presented is intended for educational and training purposes only. It is not intended to be legal advice. Always seek the advice of an attorney for legal-related questions regarding proper coding and billing practices.

The information presented has been researched by the author and is current as of the publishing date of this article. CDT codes are updated annually and effective on January 1 of each year. Invest in current coding manuals and training for your entire team on an annual basis to ensure proper documentation, coding, and billing practices.

The Code on Dental Procedures and Nomenclature is published in CDT 2025: Current Dental Terminology, Copyright © 2024 American Dental Association (ADA). All rights reserved. ADA is the exclusive copyright owner of CDT, the Code on Dental Procedures and Nomenclature (CDT Code), and the ADA Dental Claim Form.

Copyright ©2025 Tidewater Consulting Services, LLC. All rights reserved.

Coding can be complex and challenging at times. It is not to be taken lightly. The three things dental teams should know about up front about coding are discussed in this article. It has been my experience that there is very little reliable education about coding for dentists and dental teams.  So, I want to offer a starting point for your journey.

First, things first- Proper Coding Ensures Proper Reimbursement!

Coding is an area of compliance that is often overlooked in the dental practice. Documenting what we do and why we do it is crucial. A starting point is to understand the three overarching coding principles that apply to our profession.

Three Code Sets That May Apply to Dentistry

In dentistry the one code set dental teams are most familiar with is Current Dental Terminology known as CDT. CDT is the standard code set used to document dental procedures rendered to patients in a uniform fashion under the HIPAA act of 1996. CDT codes are also used to report procedures to third-party payers such as a dental or medical insurance plan for reimbursement consideration.

Sometimes, we find that dental procedures we perform in the dental practice are considered medical in nature and find it necessary to send a claim to a patient’s medical plan. These include procedures related to dental trauma, biopsies, sleep apnea appliances and much more. 

When submitting procedures to a medical payer, a Current Procedural Terminology code, known as CPT® is used to report the procedure. Sometimes the CDT code is reported when there is no accurate CPT code available to describe the dental procedure performed. Coding guidelines are that the provider is to use the code that most accurately describes the procedure performed. Sometimes, this is the CDT code. It takes a little training time and practice – but your teams can learn when to use CPT and when to use CDT.

One important gem I can offer is that while a CDT code may be reported to medical payers when appropriate, a CPT code will never be reported to a dental payer. 

Another standard transaction code set dental teams are not as familiar with is diagnosis codes. Diagnosis codes are utilized to establish medical necessity, the why. Why was the procedure required; what medical or dental condition are you treating? For many years in dentistry we have described why we perform procedures and what we do via narrative on a dental claim form. The good news is that we don’t have to narrate this anymore!  The ICD-10 CM is the code set used by physicians, dentists and other healthcare providers to document and report diagnoses. It has been in effect since October 1, 2015. There are currently over 73,000 codes, so yes there is a code for that! Whatever the condition you’re treating there is a code to describe it. 

Instead of attaching a lengthy word narrative to a dental claim we can utilize a diagnosis code in place of a narrative. This is a standard way of communicating the why of a patient encounter. And aids in adjudication or processing of the claim. 

It’s not enough to know the three codes. Each of these codes have guidelines that must be followed with them. Possibly the most important reference is that anyone reading the patient’s record should be able to recognize the code used as documented and understand what services were delivered and why the services were necessary. Our documentation tells the story of the patient encounter.  So, how do you do this efficiently and effectively as a practice? How do you know if all of your team knows how to tell the story?

Next Step

This can be challenging because all codes are reviewed and revised on an annual basis. Annual training of the entire team should be held prior to the effective date of the code, which is January 1 of each calendar year for CDT and CPT.  ICD 10 code set is also updated on an annual basis however it becomes effective October 1 of each year instead of January 1. You don’t have to go it alone, we’re here to help!