D9245 Dental Code: Moderate Enteral Sedation Billing Guide

What D9245 covers and doesn’t cover

D9245 reports moderate sedation administered via an enteral route. Enteral means the drug enters through the gastrointestinal tract or oral mucosa: swallowed tablets, sublingual tablets, rectal suppositories, or oral liquids. In CDT 2026, the enteral route is coded as moderate sedation (D9245 rather than D9244) when either condition is met: more than one sedative drug is administered enterally, or a single enteral drug is given above the FDA maximum recommended dose (MRD) for unmonitored home use. Clinically, moderate sedation (also called conscious sedation) is a drug-induced depression of consciousness in which the patient responds purposefully to verbal commands, either alone or with light tactile stimulation, while maintaining protective reflexes and adequate spontaneous ventilation, but the code itself is triggered by the drug protocol, not by grading the depth in the chair.

Nitrous oxide may be co-administered with the enteral drugs. When it is, the nitrous is part of D9245 and is not billed separately (D9230 is only for nitrous used as the sole agent), though its administration still has to be documented in the clinical notes.

The code includes drug administration, patient monitoring during the sedation period, and recovery observation before discharge. It is reported once per visit.

D9245 does not cover:

• Minimal sedation (anxiolysis) with a single enteral drug. Use D9244.
• Moderate sedation via non-intravenous parenteral routes (intramuscular, intranasal). Use D9246 (first 15 minutes) or D9247 (each additional 15 minutes).
• IV moderate sedation. Use D9239 (first 15 minutes) or D9243 (each additional 15 minutes).
• Deep sedation or general anesthesia. Use D9222 (first 15 minutes) or D9223 (each additional 15 minutes).
• General anesthesia with advanced airway management. Use D9224 (first 15 minutes) or D9225 (each additional 15 minutes).
• Nitrous oxide alone. Use D9230.
• The dental procedure performed under sedation. That has its own code.

The code is specific to moderate sedation via enteral route. If the route is parenteral or IV, or the depth is minimal or deep, a different code applies.

When to bill D9245

Bill D9245 when:

• A patient received one or more enteral sedative drugs and the intended and documented sedation level was moderate (conscious sedation).
• The patient responded purposefully to verbal commands throughout the procedure but had depressed consciousness beyond simple anxiolysis.
• The provider holds the appropriate state sedation permit for moderate sedation.
• The patient was monitored per the state board’s and ADA’s standards for moderate sedation (pulse oximetry, blood pressure, heart rate, respiratory rate at defined intervals).

Do not bill D9245 for:

• Cases where the patient remained fully alert and responsive with only mild relaxation. That is minimal sedation (D9244).
• Deep sedation where the patient could not be aroused by verbal commands alone. That is D9222/D9223.
• Non-oral routes of administration (IM, intranasal, IV), even if the sedation level was moderate.
• Nitrous oxide used as the sole agent. Use D9230 regardless of the patient’s response level.
• A take-home prescription without in-office administration or supervised monitoring.

D9245 versus D9244 and other sedation codes

The 2026 sedation code restructuring split the older bundled codes into precise tiers by sedation depth, route of administration, and (for some) time increments. Here is how D9245 fits relative to the codes around it.

D9244 (minimal sedation, single drug, enteral): One sedative agent given at or below the FDA maximum recommended dose. Clinically the patient is awake and responds normally to verbal commands. Typical scenario: a single low-dose oral benzodiazepine for anxiety reduction.

D9245 (moderate sedation, enteral): More than one enteral drug, or a single enteral drug above the MRD. Monitoring requirements are more extensive than for minimal sedation. Typical scenario: a hydroxyzine-plus-midazolam oral protocol, or a single agent dosed above its MRD for a longer or more involved procedure.

D9246/D9247 (moderate sedation, non-IV parenteral): Same sedation depth as D9245, but the route is parenteral (intramuscular, intranasal, submucosal) rather than enteral. These are time-based (first 15 minutes, each additional 15 minutes).

D9239/D9243 (IV moderate sedation): Same sedation depth, but the route is intravenous. Time-based billing.

D9230 (nitrous oxide): Used only when nitrous oxide is the sole sedative agent. If the practice’s protocol combines nitrous with an oral sedative, the nitrous is part of D9245 (or D9244) and is not reported separately. Per the ADA’s 2026 guidance, D9230 and a sedation code are never billed together for the same visit. Document the nitrous in the clinical notes.

D9219 (evaluation for moderate sedation, deep sedation, or general anesthesia): A separate code for the pre-sedation evaluation. Per the ADA’s 2026 guidance it can be reported on the same date of service as D9245 to document the doctor’s safety check before sedation begins.

The drug protocol determines the code, not the depth graded in the chair. A single enteral drug at or below the MRD is D9244 even if the patient looks deeply relaxed; multiple enteral drugs, or a single drug above the MRD, is D9245. Code what the protocol supports.

New code, carrier lag

D9245 is effective January 1, 2026. As of mid-2026, not all carriers have loaded the new sedation codes into their adjudication systems. This is the same adoption-lag pattern that follows every CDT release, and it typically takes six to twelve months for full carrier adoption.

What this looks like in practice:

• Claim rejected as “code not recognized.” The carrier’s system doesn’t have D9245 in its code table yet. This is not a coverage denial. It is a system-update issue.
• Claim processed but with a $0 fee schedule. The carrier loaded the code but hasn’t assigned an allowable. This looks like a non-covered service on the EOB but is really a fee-schedule gap.
• Carrier asks you to resubmit under the old code. Some carriers will tell you to use D9248 (the pre-2026 catch-all for non-IV conscious sedation) until they complete the transition. D9248 was deleted effective January 1, 2026, so this means billing a now-deleted code as a stopgap, fine when the carrier requests it, but switch to D9245 once their system is updated.

Provider licensure and sedation permits

State dental boards regulate sedation permits independently of CDT codes and insurance billing. Most states require a separate permit for moderate sedation that is distinct from (and a tier above) the minimal sedation permit. The specific permit names and requirements vary by state.

Common requirements for a moderate sedation permit include:

• Completion of ADA-recognized training in moderate sedation (typically 60+ hours of didactic and clinical instruction, though state requirements vary).
• Current ACLS or PALS certification.
• Office inspection demonstrating appropriate monitoring equipment (pulse oximeter, blood pressure monitor, emergency drugs, supplemental oxygen, suction).
• A trained sedation assistant present during the procedure.
• Permit renewal on the state board’s cycle, usually every two to five years.

If the provider does not hold the required permit, the carrier may deny the claim. But the bigger problem is regulatory: performing moderate sedation without the proper state permit is a violation that carries consequences beyond a claim denial. Confirm the provider’s permit status before adding moderate sedation services to the practice.

Top reasons D9245 gets denied

Six issues account for most denials on this code in 2026:

1. Code not recognized by the carrier. The carrier hasn’t loaded CDT 2026. Call, confirm, and if needed resubmit under the deleted D9248 as a transition stopgap, then switch to D9245 once the carrier updates.
2. Plan doesn’t cover sedation. Many dental plans exclude sedation entirely or cover it only for specific populations (pediatric patients, special needs patients) or specific procedures (oral surgery). The denial reads “non-covered service.” The patient owes the full fee out of pocket.
3. Medical necessity not documented. Plans that do cover sedation often require a narrative explaining why moderate sedation was clinically necessary. Without it, the claim pends or denies. Common justifications: severe dental anxiety unresponsive to behavioral management, strong gag reflex preventing standard treatment, extensive or lengthy procedure, special needs patient.
4. Provider lacks the sedation permit. Some carriers verify the provider’s sedation permit against the state board’s records. If the permit isn’t on file or has lapsed, the claim denies.
5. Wrong code for the sedation level. D9245 billed when the chart documents minimal sedation (should be D9244), or D9245 billed when the route was parenteral (should be D9246/D9247). The chart documentation must support the code.
6. Bundling with the procedure. Some plans bundle sedation into the procedure allowable and won’t pay the sedation code separately. Appeal with documentation showing the sedation was a distinct service with its own monitoring, timing, and clinical notes.

Documentation that supports the claim

The claim submission needs:

• Date of service.
• D9245 as the sedation code.
• Procedure code(s) for the dental work performed under sedation.
• Medical necessity narrative (recommended on every sedation claim, required by many carriers).

For the patient record, document all of the following:

• Pre-sedation assessment: medical history review, current medications, ASA physical status classification, baseline vital signs, informed consent signed.
• Drug protocol: drug name(s), dosage(s), route of administration (oral, sublingual, rectal), time of administration.
• Monitoring during sedation: pulse oximetry, blood pressure, heart rate, and respiratory rate recorded at regular intervals (typically every five minutes, per state and ADA guidelines for moderate sedation). Note the patient’s responsiveness level at each check.
• Sedation start and end times.
• Patient’s level of consciousness throughout: responsive to verbal commands, any tactile stimulation required to elicit response.
• Recovery observation: vital signs returning to baseline, patient meeting discharge criteria (oriented, ambulatory with assistance, stable vitals).
• Discharge: time of discharge, confirmed responsible adult driver present, written post-sedation instructions provided.
• Provider’s sedation permit number if the state board requires it in the record.

A pre-printed sedation record template that the assistant fills in during the visit is the most reliable way to capture all of this without gaps.

Example case

A 42-year-old patient with severe dental anxiety and a strong gag reflex presents for extraction of a failing upper right first molar (#3) and bone grafting. The dentist treatment-plans the procedures under moderate oral sedation. The patient has a history of failed minimal sedation (single-drug oral protocol did not achieve adequate sedation for a prior procedure).

Treatment sequence:

1. Pre-sedation assessment completed at check-in: medical history reviewed, ASA Class II (controlled hypertension), vital signs recorded, informed consent for moderate oral sedation signed.
2. Oral triazolam 0.5mg administered at 8:00 AM. Second dose of 0.25mg administered sublingually at 8:20 AM per the moderate sedation protocol.
3. Patient taken to the operatory at 8:45 AM. Responds to verbal commands but shows depressed consciousness consistent with moderate sedation. Baseline monitoring recorded: SpO2 98%, BP 128/82, HR 72, RR 14.
4. Local anesthesia administered. Extraction of #3 (D7210) and bone graft (D7953) completed.
5. Vital signs monitored every five minutes throughout the procedure. All readings within normal limits. Patient responded purposefully to verbal commands at each check.
6. Procedure completed at 9:40 AM.
7. Recovery monitoring. Patient meets discharge criteria at 10:15 AM: oriented, ambulatory with assistance, vital signs stable. Discharged with responsible adult driver. Written post-sedation instructions provided.

Billing steps:

1. Verify benefits before treatment. Confirm that the plan covers moderate sedation and ask about any required pre-authorization. If sedation is not covered, quote the patient the full sedation fee as out of pocket.
2. Submit on the date of service:
   • D7210 (surgical extraction) on tooth #3.
   • D7953 (bone graft) on site #3.
   • D9245 for the moderate enteral sedation.
3. Attach a medical necessity narrative: “Patient with documented severe dental anxiety and gag reflex, with prior failed minimal sedation attempt. Moderate enteral sedation administered to enable surgical extraction and bone grafting. Patient monitored throughout, procedure completed without complication.”
4. If the carrier rejects D9245 as unrecognized, call to confirm CDT 2026 adoption status. Resubmit under the deleted D9248 with a note as a stopgap if the carrier requests it, then switch back to D9245 once their system is updated.

What to get right in your PMS

The specifics vary across Open Dental, Dentrix, Eaglesoft, Curve, and Carestream. The steps that matter are the same regardless of system:

1. Add D9245 to your procedure code table. This is a new 2026 code. If your PMS received the CDT 2026 update, the code should be present. If it isn’t, add it manually with the correct fee and a default category. Confirm the update was installed.
2. Set the fee on D9245. A missing fee means the code posts at $0, which cascades into incorrect patient estimates and incorrect claim amounts.
3. Link the sedation record to the claim. Your sedation monitoring notes (vitals, times, drug protocol) should be attachable to the claim. Many systems store clinical notes at the patient level by default. Make sure the sedation documentation is linked to the specific claim, not just the chart.
4. Flag carrier adoption status. Add a note or flag on each carrier record indicating whether they’ve loaded CDT 2026 sedation codes. This prevents your team from submitting D9245 to a carrier that will reject it, saving a round-trip.
5. Use a sedation-specific clinical note template. A template that prompts for drug name, dose, route, administration time, vital signs at intervals, and discharge criteria prevents documentation gaps that lead to denials or audit issues later.