D9223 Dental Code: Deep Sedation Billing by 15-Minute Unit

What D9223 covers

D9223 reports time. Specifically, each 15-minute increment of deep sedation or general anesthesia that runs past the first increment, with the first increment reported as D9222. The procedure is identical across the two codes, and the only thing D9223 adds is duration.

That makes it an unusual code to bill, because nothing clinical distinguishes a D9223 unit from the D9222 unit before it. How many units go on the claim is decided by two timestamps, not by the chart note describing the sedation.

D9223 does not report:

• The first 15 minutes of the case. That is D9222.
• Subsequent increments of general anesthesia that required an advanced airway. Those are D9225, paired with D9224.
• Subsequent increments of IV moderate sedation. That is D9243, paired with D9239.
• Subsequent increments of moderate sedation given by a non-intravenous parenteral route, such as intramuscular or intranasal. That is D9247, paired with D9246.
• Nitrous oxide, when nitrous is the only agent given. That is D9230, a per-visit charge with no time component.

How the units accrue

The clock generally starts when the provider initiates the anesthesia and monitoring protocol and stays in continuous attendance, not merely when the first drug goes in, and it stops when the patient is stable enough to be monitored by trained staff without that continuous attendance. Recovery observation after that handoff is not billable increment time, and counting it is how an audited case loses units it appeared to earn.

Between those two timestamps the arithmetic is fixed. The first block is one unit of D9222. Every 15 minutes after that is one unit of D9223, and the CDT 2026 descriptors state the increment as 15 minutes or any portion of one, so a block that closes after four minutes is a whole unit.

Three cases, worked out:

• A 12-minute case. D9222, one unit. No D9223 at all, because there is no time past the first increment.
• A 50-minute case. D9222 for minutes 1 through 15. D9223 for minutes 16 through 30, again for minutes 31 through 45, and once more for minutes 46 through 50. Three units of D9223.
• A 92-minute case. D9222 plus six units of D9223, the sixth covering minutes 91 and 92.

The last unit is almost always partial, since a case that lands exactly on a 15-minute boundary is rare. That unit is legitimate, and it is also the one a reviewer questions first, which is why the stop time has to be a recorded number rather than an estimate written up afterward.

Depth and airway decide the family before time decides the units

Time only settles how many units. Two other questions settle which code family the units belong to, and both come first.

Depth of sedation. Deep sedation and general anesthesia reduce or remove purposeful response to stimulation. Moderate, or conscious, sedation keeps the patient responding to verbal commands and maintaining a patent airway unaided. Deep and general run on D9222 and D9223. IV moderate runs on D9239 and D9243. The record describes the plane reached, and the code family has to agree with it.

Airway management. CDT 2026 added D9224 and D9225 for general anesthesia that requires an advanced airway, meaning a supraglottic or subglottic device such as a laryngeal mask airway or an endotracheal tube. Both conditions have to hold: the patient reaches general anesthesia and the airway is in use. Where that is true, those increments are units of D9225 rather than D9223, and increments before the airway went in stay on D9223. Before 2026 there was no separate code for that case, so a practice working from an older code table will keep routing it to D9222 and D9223 out of habit.

Answer those two questions from the record, then count the blocks. Doing it in the other order produces a claim where the unit math is impeccable and the code is wrong.

Why the add-on units get denied

The first increment usually clears. The denials cluster on the units after it, for four reasons that behave differently on appeal.

A plan cap on units or total minutes. Many benefit plans and state Medicaid programs limit how many subsequent increments they pay per date of service. Published limits on D9223 have run from a single unit a day to four or more depending on the program, and some programs count D9222 and D9223 toward one combined total. A unit denied against a cap is a benefit limitation rather than a coding error, and more clinical documentation rarely moves it. Who absorbs those minutes depends on the plan. On a commercial plan, units past a benefit limit are usually patient responsibility under the contract. On Medicaid they usually are not, since balance-billing the member is prohibited unless a private-pay agreement was signed before treatment.

No start and stop times. This is the one that repeats. Without both timestamps the carrier has nothing to adjudicate the unit count against, and it denies the extra units for insufficient documentation. Attaching the anesthesia record on appeal generally fixes it, which means the practice paid for an appeal to send a document it already had.

An orphan D9223. A claim carrying subsequent-increment units with no first increment on the same date is rejected before anyone reads the chart. It happens when the D9222 got posted to a different date of service, or dropped during a claim correction.

A narrative that justifies anesthesia without justifying its length. A medical-necessity line explaining why the patient needed deep sedation supports D9222 fully and the fifth unit of D9223 barely at all. Tie the duration to the case: the number of teeth, the surgical difficulty, the behavioral situation that made a short appointment impossible.

When to bill D9223, and when not to

Bill it when:

• Deep sedation or general anesthesia was administered, no advanced airway was in place during those increments, and the documented time runs past the first 15-minute increment.
• D9222 is on the same claim for the same date of service.
• The anesthesia record carries a start time and a stop time that support the number of units reported.

Do not bill it for:

• A case of 15 minutes or less. That is D9222 alone.
• Recovery time after the provider’s continuous attendance ended.
• Subsequent increments where an advanced airway was used. Those are units of D9225.
• Subsequent increments of IV moderate sedation (D9243) or non-intravenous parenteral moderate sedation (D9247).
• Nitrous oxide running alongside the anesthetic. Under the 2026 changes it is part of the anesthesia service, so D9230 does not go on the claim as an extra line.

Documentation that supports every unit

A D9222 claim asks the carrier to accept that deep sedation happened. A D9223 claim asks it to accept a duration, which is harder to prove after the fact. The anesthesia record generally needs:

• Start time, defined as when the provider initiated the anesthesia and monitoring protocol and began continuous attendance.
• Stop time, defined as when the provider’s continuous attendance ended, recorded separately from the discharge time.
• The depth of sedation reached, so the case sits in the deep and general family rather than the moderate one.
• The airway technique, including whether an advanced airway was placed, which decides between D9223 and D9225.
• Drugs, doses, routes, and the times they were given. Intraoperative dosing entries corroborate a long case better than anything else, since they show the provider managing the patient across the span being billed.
• Vital signs recorded at intervals across the whole case. A monitoring log that stops 20 minutes before the claimed stop time undercuts the last units.
• A necessity narrative that addresses length, tying the duration to the procedure or the patient’s condition.

Write the times as they happen. Reconstructed timestamps are the first thing an anesthesia audit challenges, and they are hard to defend against a monitoring log that says something else.

What to get right in your PMS

The screens differ across Open Dental, Dentrix, Eaglesoft, Curve, and Carestream, but the setup is the same:

1. Set D9223 up as a quantity code rather than a repeated line. Post one D9223 with a units value matching the block count instead of five separate lines, which some clearinghouses collapse and some carriers read as duplicates.
2. Add a claim edit that blocks D9223 without D9222 on the same date. The orphan add-on is a rejection the software can prevent outright, and it costs nothing to configure once.
3. Store start and stop time as structured fields on the sedation note. Fields can be required, reported on, and audited. A narrative paragraph with the times buried in it cannot.
4. Derive the unit count from the times instead of typing it. A calculated field, a chairside worksheet, or a step in the biller’s checklist all work, and any of them removes the guess that produces both undercounting and the overcount a reviewer catches.
5. Record the plan’s unit cap on the benefit record during verification. Anesthesia caps are specific enough that a general benefit breakdown misses them, and the cap is the number the treatment estimate depends on.
6. Keep D9225 labeled as the advanced-airway add-on, adjacent to D9223 in the code list. Both report subsequent increments at a deep plane, and only the airway separates them.

Long sedation cases are among the higher-dollar lines a general practice submits, and the units at the end decide whether one gets paid in full. For how the anesthesia lines sit on the rest of the claim, see the ADA dental claim form guide.