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

What D9223 covers

D9223 reports each 15-minute increment of deep sedation or general anesthesia after the first increment, which is reported as D9222. The procedure is identical across the two codes; D9223 adds only duration. Nothing clinical distinguishes a D9223 unit from the D9222 unit before it, so the number of units is decided by two timestamps, not by the 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 by a non-intravenous parenteral route, such as intramuscular or intranasal. That is D9247, paired with D9246.
• Nitrous oxide as the only agent. That is D9230, a per-visit charge with no time component.

How the units accrue

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

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.

• A 12-minute case. D9222, one unit. No D9223.
• A 50-minute case. D9222 for minutes 1 through 15, then D9223 for minutes 16 through 30, 31 through 45, and 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. It is legitimate, and it is also the one a reviewer questions first, so the stop time has to be a recorded number rather than an estimate written afterward.

Post D9223 as one line with a units value matching the block count, not as repeated lines, which some clearinghouses collapse and some carriers read as duplicates. Deriving the unit count from the recorded times, through a calculated field, a chairside worksheet, or a biller checklist step, prevents both undercounting and overcounting.

Depth and airway decide the family before time decides the units

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

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. When the patient reaches general anesthesia and the airway is in use, those increments are units of D9225 rather than D9223; increments before the airway went in stay on D9223. Before 2026 there was no separate code for this case, so a practice using an older code table will keep routing it to D9222 and D9223. Keep D9225 labeled as the advanced-airway add-on, next to D9223 in the code list.

Answer both questions from the record, then count the blocks. In the other order, the unit math can be correct and the code wrong.

Why the add-on units get denied

The first increment usually clears. Denials cluster on the later units, for four reasons that behave differently on appeal.

A plan cap on units or total minutes. Many plans and state Medicaid programs limit subsequent increments per date of service. Published limits on D9223 have run from one unit a day to five, and some programs count D9222 and D9223 toward one combined total. A unit denied against a cap is a benefit limitation, and more documentation rarely moves it. 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 one recurs. Without both timestamps the carrier has nothing to adjudicate the unit count against and denies the extra units for insufficient documentation. Attaching the anesthesia record on appeal generally fixes it, which means paying for an appeal to send a document the practice already had.

An orphan D9223. A claim with subsequent-increment units and no first increment on the same date is rejected before anyone reads the chart. It happens when D9222 was posted to a different date or dropped during a claim correction. A PMS claim edit that blocks D9223 without D9222 on the same date prevents it.

A narrative that justifies anesthesia but not its length. A 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, or 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 has start and stop times that support the number of units.

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.
• 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, when the provider initiated the anesthesia and monitoring protocol and began continuous attendance.
• Stop time, when the provider’s continuous attendance ended, recorded separately from the discharge time.
• The depth of sedation reached, placing the case 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 billed span.
• 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.

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 otherwise. Store start and stop times as structured fields on the sedation note, which can be required and audited, rather than buried in a narrative paragraph. For how the anesthesia lines sit on the rest of the claim, see the ADA dental claim form guide.