coding and insurance...
TRANSCRIPT
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AAPD Coding and Insurance Workshop
Mary EsslingAAPD Dental Benefits Manager
California Society of Pediatric Dentistry
Rancho Mirage, CA
April 28 , 2013
Why Do CDT Codes Exist?
• Purpose Provides uniformity, consistency and specificity in
accurately reporting/documenting dental treatment
• Use Populates patient health record — electronic and paper
Provides for efficient processing of dental claims
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CDT Basics
D1351 Code Number
Sealant – per tooth Nomenclature
Mechanically and/or chemically prepared enamel surface sealed to prevent decay
Descriptor
CDT Basics
Code for what you do, not what you are paid for.
Just because a code exists does not mean that it may be a paid benefit or covered service in a dental insurance plan
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Decisions Current Dental Terminology (CDT) maintained by
the ADA Code Maintenance Committee (CMC) Twenty-one members 5 ADA Members (one will serve as Chair) 9 Reps from each of specialty organizations 1 Rep from AGD 5 Reps from third-party payers DDPA (Delta Dental Plans of America) AHIP (America’s Health Plans of America) CMS (Centers for Medicare and Medicaid) BCBS (Blue Cross Blue Shield Association) NADP (National Association of Dental Plans)
1 Rep from ADEA (American Dental Education Association)
Code Revision Process
Contact AAPD Dental Benefit Manager May be able to suggest alternative code
May have suggestions on proper submission of existing code
May have idea of need based on number of calls
Contact your AAPD District Representative — Dr. Reggiardo
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CDBP District Representatives
Eli Schneider (I)
Katherine Wezmar Poepperling (II)
Ashley Patnoe (III)
Brent D. Johnson (IV)
Brynn Leroux (V) Paul Reggiardo, Chair (VI)
Code Revision Process
Review by AAPD Important Annual Review starting in 2013
Submit completed form to AAPD staff
Council can suggest wording to improve chance of passage
Code Revision Process
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CDT 2013Changes Effective January 1, 2013
36 new codes
37 revised codes
12 deleted codes
Classification of Materials
Relocated to precede all categories of service
Revised descriptor for Porcelain/Ceramic material:
Refers to pressed, fired , polished or milled materials containing predominantly inorganic refractory compounds including porcelains, glasses, ceramics and glass ceramics.
This language now covers new materials that did not fit into the previous description of porcelain/ceramic materials.
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Diagnostics – Major Actions
Revision and expansion of Diagnostic Imaging subcategory
Evolutionary changes to imaging modalities
New subcategory for Pre-diagnostic Services
Regulatory changes for increased patient access to care
Diagnostic Imaging – 3 Sub-subcategories
Image capture with interpretation Continuing image capture and interpretation
(e.g., FMX; BWX) within the dentist’s office
Image capture only
Separate facilities for MRI, Ultrasound and other special imaging
Interpretation and report only
Practitioner s who specialize in analyzing diagnostic images
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Change “film” to “radiographic image”
“Film” is out of date
All nomenclature with “film” revised
Example –
Before change:
D0270 bitewing – single film As revised D0270 bitewing – single radiographic image
Pre-diagnostic Services
D0190 — screening of a patient A screening, including state or federally mandated screenings, to determine an individual’s need to be seen by a dentist for diagnosis.
D0191 — assessment of a patientA limited clinical inspection that is performed to identify possible signs of oral or systemic disease, malformation, or injury, and the potential need for referral for diagnosis and treatment.
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Preventive – One for two
One addition to replace two deletions
o New:D1208 topical application of fluoride
o Deleted: D1203 and D1204
Why?o Topical fluoride (gel, foam) is applied
in same manner for both dentitions
Preventive – One revision
Before change:
D1206 — topical fluoride varnish: therapeutic application for moderate to high caries risk patients
Application of topical fluoride varnish, delivered in a single visit and involving the entire oral cavity. Not to be used for desensitization.
As revised:
D1206 — topical application of fluoride varnish
Why?
No reason why varnish application should be constrained by level of caries risk.
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Restorative -Highlighting 2 revisions
D2940 — protective restoration
Removed “temporary” from qualifier so that it can be used as more definitive restoration such as ITR.
There will be a new ITR code in 2014. AAPD was instrumental in getting this passed
• D2990 — resin infiltration of incipient smooth surface lesionsPlacement of an infiltrating resin restoration for strengthening, stabilizing and/or limiting the progression of the lesion.
• D2929 — prefabricated porcelain/ceramic crown – primary tooth
Restorative -Highlighting 2 revisions
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OLD
D2799 provisional crown
Crown utilized as an interim restoration of at least 6 months duration during restorative treatment to allow adequate time for healing or completion of other procedures. This includes, but is not limited to changing vertical dimension, completing periodontal therapy or cracked tooth syndrome. This is not to be used as a temporary crown for a routine prosthetic restoration.
No more arbitrary time criteria required
D2799 provisional crown –further treatment or completion of diagnosis necessary prior to final impression.
Not to be used as a temporary crown for a routine prosthetic restoration.
Restorative -Highlighting 2 revisions
Adjunctive General Services
Addition
D9975 — external bleaching for home application, per arch: includes materials and fabrication of custom trays
Revision
D9972 — external bleaching – per arch - performed in office
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Preventing Claim Errors
Unintended errors are most often caused by misunderstanding or misinformation
Right Codes for Dental Claims
Primary code source for pediatric dental claims:
AAPD Coding and Insurance CD ROM 2013
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No code to describe a procedure?
Unspecified ….procedure by report codes are:
For those situations where, in the opinion of the dentist, none of the entries in the CDT Code accurately describe the services provided
They are in each category of service except for Preventive (2014 will have a 999 code)
Avoiding procedure coding errors
By report - A clear and concise narrative should include:
Clinical condition of the oral cavity
Description of the procedure performed
Specific reason why the extra time or material was necessary
How new technology enabled procedure delivery
Any specific information required under a participating provider contract
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By report codes
A third-party payer is likely to return the entire claim if the narrative is missing
Even when the narrative is present, the carrier may request additional information
New codified data
Up to four diagnoses may be reported for each procedure on a claim
Reporting is discretionary
May be reported on the HIPAA standard electronic dental claim and the ADA’s paper claim form
Codes used in the public domain
ICD-9 CM (now)
ICD-10 (2014 or 2015)
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Coding for Reimbursement
Q: What codes have the best chance for reimbursement
A: Codes for procedures that are covered by the patient’s dental benefit plan
Your treatment plan should be based on the patient’s clinical needs and NOT the covered procedures!!!!
Coding for Reimbursement
The Facts of Life –
Not all procedures are covered
Some have annual or lifetime limitations
Limitations and exclusions can vary between plans offered by the same company
HIPAA only requires that a payer accept a valid procedure for processing
HIPAA does not require that a payment for every procedure in the CDT Code
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Determining the Date of Service
Q: When there is a single code for a procedure that requires multiple appointments, how do I determine the date of service?
ADA policy for fixed and removable prosthetic cases encourages payers to use the date of impression as the date of service
Some state laws and third party processing policies and contract provisions specify completion date as the date of service
Determining the Date of Service
Weigh all of these factors when determining date of service reported for the procedure code
Be consistent and compliant with policy, regulations and contract provisions
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Claim Coding Confusion
There may be many reasons why a dentist or staff may be unsure about the procedure code to use:
Infrequent delivery of the procedure
Conflicting information from peers or third-party payers
Guidance is based on the published procedure code nomenclatures and descriptors
Consultation Or Evaluation?
When is it appropriate to code for a consultation (D9310) versus an evaluation e.g., D0140)?
A consultation occurs when Dentist A refers a patient to Dentist B for an opinion or advice on a particular problem Dentist A reports the appropriate oral evaluation code
Dentist B reports the consultation code D9130
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Panoramic + BWXs = FMX?
Panos and BWXs are NOT considered to be an FMX
A full mouth series (aka FMX) is defined in the descriptor of D0210 intrqaoral, complete series….”
A set of introral radiographs usually consisting of 14 to 22 periapical and posterior bitewing images intended to display the crowns and roots of all teeth, periapical areas and alvelar bone crest.”
Panoramic + BWXs = FMX?
Third party payers sometimes bundle claims for the pano and bitewing(or pariapical) images and calculate reimbursement using the FMX D0210 fees
The ADA considers this a potentially fraudulent practice that should be appealed because” D0210 reimbursement is likely to be less that amounts
paid for pano and other images Bundled payment could lead to denial of a later D0210
claim due to plan limitations.
Records of service rendered will be inaccurate
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Product vs. Procedure
Procedure codes are not product-specific or brand name-specific
Occlusal pits and fissures
When mechanical enlargement of occlusal pits and fissures is performed in conjunction with placement of a dental sealant, this preparation step is not reported separately
D1351 descriptor includes the preparation
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Occlusal pits and fissures with decay
When decay that does not extend into the dentin is present code for D1352
D1352 — preventive resin restoration in a moderate to high caries risk patient — permanent tooth Conservative restoration of an active cavitated lesion
in a pit or fissure that does not extend into dentin; includes placement of a sealant in any radiating non-carious fissures or pits
Occlusal pits and fissures with decay
The continuum ends with a third procedure code that is appropriate when decay extends into the dentin
D2391 — resin-based composite — one surface, posterior Used to restore a carious lesion into the dentin or a
deeply eroded area into the dentin. Not a preventive procedure.
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Local Anesthesia
How may I report local anesthesia as a separate procedure?
D9215 local anesthesia in conjunction with operative or surgical procedures is the procedure code for separate reporting
Benefit plan limitations and exclusions may preclude separate reimbursement for local anesthesia
Participating providers are likely unable to bill patients when anesthesia is not reimbursed
Two 2 Surface Restorations on Same Tooth
Should I report a DO and an MO on the same tooth as an MOD as carriers tell me?
No….you should report D2150 twice...one for the MO and one for the DO Some plans limit coverage when the same surface is
involved more than once on the same tooth and date and they may apply an alternate benefit based on the fee for a single restoration.
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Lasers
CDT codes are procedure based
Makes no difference in coding what instrumentation is used to achieve the result
IRM Sedative or Palliative
D2940 (protective restoration) is used for many reasons, including pain
D9910 (palliative treatment) is only for emergency treatment of dental pain
Only one of the codes can be reported
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Unfinished procedures
How to report a situation where a procedure is started but not finished
CDT does not have codes for incomplete procedures
Use D2999 for unfinished procedures along with a narrative
When claim is denied
The existence of a code does not mean that the procedure is a covered or reimbursed benefit
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OK or NOT OK? NOT OK — you report D1110 and payer says you
should report D1120 for reimbursement
Patient is 13 with predominantly adult dentition and plan design defines adult to be 15 years of age
OK — for payer to accept D1110 and pay at D1120 based on plan design
OK or NOT OK?
You report D0120, D1120 and D1208 Payer says that these are not separate
procedures
Payer says all three are part of D0120
NOT OK –
Payer is redefining D0120Payer may be bundling
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OK or NOT OK? EOB to patient shows different codes than were
submitted by your office
Claim form: D0120 and D1110
EOB: D0120 and D1120
Message says that these are the correct codes for child pxs
NOT OK: payer implication is that dentist reported incorrectly
Preventing and Resolving CDT Code Errors
Prevention is always best Questions concerning proper coding should be
addressed as the claim is prepared
There should be quality review before submission
• Otherwise payer rejects the claim or sends back requesting additional info
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Preventing and Resolving CDT Code Errors
Questions about accuracy?
Use CDT Manual as your guide
Ask dentist who performed the service
Preventing and Resolving CDT Code Errors
Contact Mary Essling at 312-337-2169 or email [email protected]
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Preventing and Resolving CDT Code Errors
Review returned or denied claims to endure that the proper codes were submitted
If coding error, prepare and submit the corrected claim
When no coding error, prepare an appeal if appropriate
Payer Error Should Be Appealed
Patient is 13 years old with predominantly adult dentition
Payer instructs you to bill D1120 for child pxsbecause plan design defines child up to age 15
Payer is asking you to miscode
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Payer Error Should Be Appealed
You report D0120, D1120 and D1203 but the payer says these are not separate procedures
Payer is ignoring the descriptors and redefining procedure code – this is a copyright violation
Payer is bundling – potential fraudulent act
Contract Provisions and Limitations
Contracts include limitations and exclusions such as: Child prophy reimbursed thru age 15 No more than two D4910 procedures per
calendar year
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Contract Provisions and Limitations
What does the contract say?
What are your par provider contract provisions? Did you agree to the LEAT clause?
Dentist who signs a par provider contract is bound to its legally sound provisions. KNOW WHAT YOU ARE SIGNING!
ADA Paper Claim Form
Latest version effective July 2012
Key change is ability to report ICD-9 diagnosis codes (Box 34)
Comprehensive instructions on ADA.org
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Fractured Tooth – After Hours Visit
Patient presents to office on day when office is closed
Dr. performs:
D0140 — limited oral evaluation — problem focused
D2970 — temporary crown (fractured tooth) D9440 – office visit — after regularly
scheduled hours
Note the Difference
D1351 — A sealant placed on the enamel surface to prevent decay. The enamel surface is non-carious.
D1352 — A conservative restoration of an active cavitated lesion in a pit or fissure, which does not extend into dentin — also includes placing a sealant in any radiating non-carious fissures or pit.
D2391 — A one-surface posterior composite restoration where the caries and preparation extend into the dentin or a deeply eroded area into the dentin.
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Preventive Resin Restoration
Documentation Critical Detailed documentation is critical to avoid healthcare fraud!!
For example, if you performed a PRR on tooth #30, record in patient’s chart – caries removed, lesion extended 2mm into the enamel (not into the dentin) and was restored by using _____(material used).
Same goes for a restorative code…document that decay into dentin was removed.
Front desk billers must pay close attention to documentation to catch or correct errors and bill appropriately
KEY REVISIONS FOR 2011/2012
Revise - Sedative filling D2940
Revise nomenclature as follows:
D2940 protective restoration
Revise Descriptor as follows:
Direct placement of a temporary restorative material to protect tooth and/or tissue form. This procedure may be used to relieve pain, promote healing, or prevent further deterioration. Not to be used for endodontic access closure, or as a base or liner under a restoration.
Use for ART — Alternative Restorative Treatment
Not only to relieve pain – broader scope now
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Requesting a New Code for 2013 — ITR
Interim Therapeutic Restoration
Placement of an adhesive restorative material after removal of caries by hand or slow speed rotary instrumentation to restore and prevent further decalcification and caries in young pre-cooperative or uncooperative patients, patients with special healthcare needs, or when traditional cavity preparation and/or placement of traditional dental restorations are not feasible and need to be postponed.
Current Code D2940 is not appropriate when using glass ionomermaterials and is not considered temporary.
Revise Subcategory Title
Apexification/Recalcification and Pulpal Regeneration Procedures
KEY REVISIONS FOR 2011/2012
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KEY REVISIONS FOR 2011/2012
Revise Nomenclature and Descriptor
D3351 — apexification/recalcification/pulpal regeneration — initial visit (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.)
Includes opening tooth, pulpectomy, preparation of canal spaces, first placement of medication and necessary radiographs. (This procedure may include first phase of complete root canal therapy.)
Revise Nomenclature
D3352 — Apexification/recalcification/pulpal regeneration — interim medication replacement (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.)
For visits in which the intra-canal medication is replaced with new medication and necessary radiographs. There may be several of these visits.
KEY REVISIONS FOR 2011/2012
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New Code
D3354 — Pulpal Regeneration – completion of regenerative treatment in an immature permanent tooth with a necrotic pulp; does not include final restoration
Includes removal of intra-canal medication and procedures necessary to regenerate continued root development and necessary radiographs. This procedure includes placement of a seal at the coronal portion of the root canal system. Conventional root canal treatment is not performed.
KEY REVISIONS FOR 2011/2012
Pulpal Regeneration Procedures
D3351 — Initial visit to open the tooth, prepare the canal spaces, and place the initial medication Includes working radiographs
D3352 — Additional pulp disinfection procedures and interim medication replacement May require multiple visits…each reported as D3352
D3354 — Final visit may involve re-entering the tooth, irrigating the root canal system, re-initiating bleeding and sealing with MTA The final coronal restoration will depend on individual
need and be billed separately
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Revise Nomenclature and Descriptor
D7960 — Frenulectomy — also known as frenectomy or frenotomy — separate procedure not incidental to another separate procedure
Surgical removal or release of mucosal and muscle elements of a buccal, labial or lingual frenum that is associated with a pathological condition, or interferes with proper oral development or treatment.
KEY REVISIONS FOR 2011/2012
FRENOTOMIES/FRENULOPLASTIESWhen appropriate to bill
Medical or Dental Insurance?
Medical
CPT codes have global period which includes
Local anesthesia
One related evaluation and management E/M encounter immediately prior to decision for surgery or on day of surgery
Immediate post- operative care
Writing orders
Evaluating patient in recovery room
Routine post operative follow-up care
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Medical – Labial Frenotomy CPT 40806 incision of labial frenum – frenectomy Applicable ICD-9 diagnosis codes 524.71 Alveolar maxillary hyperplasia 524.72 Alveolar mandibular hyperplasia 525.20 Unspecified atrophy of edentulous alveolar
ridge 528.79 Other disturbances or oral epithelium 756.82 Other specified anomaly of muscle, tendon,
fascia, connective tissue and accessory muscle 0 day global package (all associated visits are billable)
FRENOTOMIES/FRENULOPLASTIESWhen appropriate to bill
Medical or Dental Insurance?
Medical – Ankyloglossial/tongue tie
CPT 41010 incision of lingual frenum
ICD-9 diagnosis code
750.0 tongue tie
524.02 Mandibular hyperplasia
524.74 Alveolar mandibular hypoplasia
750.12 Congenital adhesions of tongue
0 day global package (all associated visits are billable)
OR dentist may perform
FRENOTOMIES/FRENULOPLASTIESWhen appropriate to bill
Medical or Dental Insurance?
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Medical
Zplasty (4 incisions vs 1 incision)
CPT 41520 – frenuloplasty-surgical revision of frenum
90 day global period (routine post operative visits and office visit and exam on day of procedure cannot be billed separately to patient or carrier)
FRENOTOMIES/FRENULOPLASTIESWhen appropriate to bill
Medical or Dental Insurance?
Continued
ICD-9 codes that support necessity for CPT 41520 may include
524.04 Mandibular hypoplasia
529.8 Other specified conditions of the tongue
750.0 Tongue tie or ankyloglossia
750.10 Anomaly of tongue, unspecified
750.12 Congenital adhesions of tongue
FRENOTOMIES/FRENULOPLASTIESWhen appropriate to bill
Medical or Dental Insurance?
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Dental
Labial Frenotomy
CDT code D7960 — frenulectomy
Ankyloglossial/tongue tie
CDT code D7960 — frenulectomy
FRENOTOMIES/FRENULOPLASTIESWhen appropriate to bill
Medical or Dental Insurance?
Determine medical necessity
Understand coverage guidelines of patient’s medical policy
Base each decision individually
FRENOTOMIES/FRENULOPLASTIESWhen appropriate to bill
Medical or Dental Insurance?
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Revised Nomenclature D9215
D9215 local anesthesia — local anesthesia in conjunction with operative or surgical procedures
(Use when a procedure has been started but unable to complete)
KEY REVISIONS FOR 2011/2012
Revise Nomenclature and Descriptor
D9420 hospital or ambulatory surgical center call
May be reported when providing treatment care provided outside the dentist’s office to a patient who is in a hospital or ambulatory surgical center. Services delivered to the patient on the date of service are documented separately using the applicable procedure codes in addition to reporting appropriate code numbers for actual services performed.
KEY REVISIONS FOR 2011/2012
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Changes in 2009/2010 cycle, a New Code was adopted
D3222 — Partial Pulpotomy for Apexogenesis —permanent tooth with incomplete root development Removal of a portion of the pulp and
application of a medicament with the aim of maintaining vitality of the remaining portion to encourage continued physiological development and formation of the root. This procedure is not to be construed as the first stage of root canal therapy.
KEY REVISIONS FOR 2009/2010
Apexogenesis – D3222
Immature permanent toothwith pulp exposure due
to caries or trauma
Only remove the infectedpart of the pulp from the pulpchamber (partial pulpotomy)
Goal =developa root
end (apex)to avoid
apexification
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Pulpotomy D3220 (Primary)
Primary tooth with caries into the pulp
Remove all pulpfrom the pulp
chamber
Goal:To retain tooth
vitality until tooth
exfoliates
Pulpotomy D3220 (Permanent)
Permanent tooth with caries into the pulp
Remove all pulpfrom the pulp
chamber
Goal:To buy timeuntil patient
is able to proceed with RCT
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Apexification–D3351-D3353
Permanent tooth -root will never mature due to
caries or trauma
Develop acalcified barrierat root end andcomplete root
canal
Goal:To save the tooth
D9220 — Deep sedation/general anesthesia —first 30 minutes
D9221 — Deep sedation/general anesthesia —each additional 15 minutes
The level of anesthesia is determined by the anesthesia provider’s documentation of the anesthetic’s effects upon the central nervous system and not dependent upon the route of administration.
KEY REVISIONS FOR 2009/2010
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D9241 — Intravenous conscious sedation/analgesia - first 30 minutes
D9242 — Intravenous conscious sedation/analgesia — each additional 15 minutes
The level of anesthesia is determined by the anesthesia provider’s documentation of the anesthetic’s effects upon the central nervous system and not dependent upon the route of administration.
KEY REVISIONS FOR 2009/2010
D9248 — Non-intravenous conscious sedation The level of anesthesia is determined by the
anesthesia provider’s documentation of the anesthetic’s effects upon the central nervous system and not dependent upon the route of administration.
KEY REVISIONS FOR 2009/2010
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The Future of the Insurance Industry
Insurance Paradigm Shift
“The nation’s largest dental carriers (Aetna, BCBS, CIGNA, Delta, MetLife,
etc.) have been tracking their internal data for years. The preponderance
of evidence suggests that it makes more economical sense to the patient,
insurance carrier, and the employer purchasing the plan to pay for
prevention rather than paying for the restoration or extraction of teeth.
As a result, some of the nation’s largest dental plans are covering more
preventive and diagnostic services in hopes of avoiding more costly and
invasive restorative services in the future”.
Richard Celko
Aetna’s National Dental Director of Utilization Management
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Insurance Paradigm Shift
Evidenced Based Dentistry
Disease Risk Assessment
Caries
Periodontal Disease
Focus on preventive over restorative
Review and reimburse based on treatment success vs. failure rate
Insurance Paradigm Shift
Dollars spent on those with greatest needs based on risk assessment
This will effect:
the number of cleanings/year
frequency of fluoride treatment Potential for changes in reimbursement of
treatment provided
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Cost Benefits of Preventive Dentistry
Dental disease is one of the leading causes of school absenteeism for children: Children miss 51 million hours of school due to
dental problems. Workers lose 164 million work hours because
of dental disease. According to the Journal of Dental Education,
oral-related illnesses account nationally for 3.6 million days of bed disability, 11.8 million days of restricted activity and 1 million lost school days.
The cost of providing preventive dental treatment is estimated to be 10 times less costly than managing symptoms of dental disease in a hospital emergency room. Preventive care and early detection and treatment
save $4 billion annually in the United States. (Delta Dental)
Children who receive preventive dental care early in life have lifetime dental costs that are 40 percent lower than children who do not receive this care.
Cost Benefits of Preventive Dentistry
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Every American should receive the care necessary to promote good oral health.
Most dental diseases are preventable, and early dental treatment has proven to be cost effective.
Cost Benefits of Preventive Dentistry
Guideline on Caries Risk Assessment and
Management The current CAT policy was revamped into a Guideline
that:
Is more comprehensive and
will include risk assessment and management pathways
The AAPD Board approved at 2010 Annual Session
Pediatric Dentistry Reference Manual
www.aapd.org
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This new guideline recommends more specific interventions for children based upon their:
ages
parental engagement, and
assessed caries risk
Guideline on Caries Risk Assessment and
Management
Previously, the policy on risk assessment had a single assessment chart for use across all ages. Now we break down our assessment forms for dental vs non-dental healthcare providers; for dental professionals, we analyze risk for
different age ranges. We added recommendations for care based upon
these previously mentioned factors. These recommendations are based upon the best current scientific evidence we have available.
Guideline on Caries Risk Assessment and
Management
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Hygienists – take note
New guideline promotes sealants in teeth with deep fissure anatomy or developmental defects in 3-5 year olds.
No longer wait for 6 year molars before we think about sealants
And for motivated families, we‘ve added xylitol into the preventive program for some kids
Guideline on Caries Risk Assessment and
Management
Caries Management Protocol
Guideline Includes Tables For:
Caries management protocol for 1-2 year olds
Caries management protocol for 3-5 year olds
Caries management protocol for > 6 year olds
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Risk Factors Influence How aggressive we treatment plan
Restoration choice, materials used
Fluoride usage
Setting
Frequency of radiographs
How we code
How claims are adjudicated
Documentation is critical
Documentation
Key to justify treatment provided Radiographs Clinical Notes and charting
Photographs, etc
Medical Legal requirements
Utilization reviews - profiling
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How often do you take BWX
Frequency depends on patient’s needs
Caries Risk and History
Should not be dictated by patient’s benefits
Must document risk factors to justify if frequency falls outside of FDA guidelines
Occlusal films
D0240 is reported based on projection technique; not the size of the film
Carriers sometime deny coverage based on size of film for occlusal films. This is not appropriate.
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ADA/FDA Radiographic Guidelines
Recommendations for bitewing intervals vary depending on: Patient’s age Risk for caries Periodontal disease Dentofacial growth and development Restorative and endodontic needs Caries remineralization
Caries Remineralization
D1206 — topical fluoride varnish: therapeutic application for patients with moderate to high caries risk
Not to be used for desensitization
Patient has moderate to high caries risk if one or more factors apply
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Fluoride Varnish It is concentrated: 5% NaF in a resin base.
It can be used as a topical fluoride, especially in pre-cooperative youngsters. When used in this fashion on children with low caries
risk, D1203 applies. If you use Fl varnish across the board, must bill D1203 for low caries risk
It can be used to retard, arrest and reverse the caries process in children with moderate to high caries risk. When used in this fashion, D1206 applies. Application frequency as often as quarterly.
Why was Fluoride Varnish Applied?
D1203/D1204 Preventive protocols Low caries risk patients
D1206 Therapeutic Moderate to high caries risk patients
D9910 Desensitization
Root sensitivity Thermal sensitivity
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New ProductICON
New composite product ICON by DMG America that penetrates the dentin. Carriers are not covering this technique currently.
Patients should be informed that they must pay out of pocket for this in advance.
DMG has put forth a proposals for a new codes for both applications in CDT 2013
resin infiltration of facial non-cavitated lesion
resin infiltration of proximal incipient lesions
New ProductPre-fab milled zirconium
crown-primary AAPD put forth a request for a new code (CDT-2013) for
D29XX — prefabricated porcelain/ceramic crown — primary tooth
A pre-fabricated, individually-milled zirconium crown for both anterior and posterior primary teeth has been introduced into the marketplace and into clinical practice.
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The Dental Home
A professional environment where a child’s oral health care is delivered in a comprehensive, continuously accessible, coordinated and family-centered way by a licensed dentist.
The Age One Visit
The AAPD recommends the child’s first visit to be no later than age one, but preferably within six months of the first tooth’s eruption.
By visiting the dentist at that time, a Dental Home can be established and Anticipatory Guidance be made part of the child’s total health care experience.
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The Infant Oral Exam (D0145)
DO145 — Oral evaluation for a patient under three years of age and counseling with a primary caregiver
Diagnostic services performed for a child under the age of three, preferably within the first six months of the eruption of the first primary tooth, including the recording the oral and physical health history, evaluation of caries susceptibility, development of an appropriate preventive oral health regimen and communication with and counseling of the child’s parent, legal guardian and/or primary caregiver.
D0145: The responsibility of the industry
It is incumbent upon third party administrators and vendors to:
Educate their product purchasers as to the reasons for the inclusion of D0145 into the CDT.
Encourage purchasers and decision makers to include this procedure into the chosen benefit package
Avoid down-coding or establishing lower remuneration
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D0145Appropriate Reporting
May report this as often as necessary before age three
Compliant patients may “advance” to the D0120
Non-compliant patients may need repeated education, counseling and encouragement. This is the D0145!
Strip Crowns
Code as a restoration…not as a crown
Typically it is coded as D2335 — resin-based composite — four or
more surfaces or involving the incisal angle (anterior)
D2394 — resin-based composite — four or more surfaces,posterior
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Aesthetic Stainless Steel Crowns
Pediatric dentists should have choice/ freedom to use what type of crown is most appropriate for patient based on risk factors, age, etc.
D2933 pre fab esthetic SSC w/ resin window
D2934 pre fab esthetic SSC D2335 composite strip crowns
Space maintainers
Some carriers will cover unilateral space maintainers but not bilateral space maintainers –force dentists to bill unilateral twice.
AAPD discussed this with the carriers at the Insurance Summit in May
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Medical Billing Resource
Instructions on medical billing and documentation included in the AAPD Coding and Insurance Manual
Effective January 1, 2011 to December 31, 2012
Common Medical Billing Situations for Pediatric
Dentistry Trauma related dental procedures
Biopsies and excisions
Surgical excisions
TMJ conditions
Restorations due to GERD, bulimia, saliva-inhibiting medications
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Administrative Challenges
Administrative Challenges Appealing denied claims
Prompt payment laws
Overpayment refund requests
Fees
Coordination of benefits
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Fully Insured Dental Plans
Traditional insurance
Carrier is at risk for payment of claims
Dental plan is regulated by the Department of Insurance in the state where it is licensed/sold
Self-Funded Dental Plans Also called Administrative Services Only or Administrative
Services Contract
Trend – this is majority of plans today
Employer bears the entire risk of utilization
Third Party administrators provide claims processing and other administrative services without bearing risk of utilization
Regulated by Employee Retirement Income Security Act of 1974 (ERISA), not the State Department of Insurance
Does not need to abide by State Insurance Regulations
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Writing Narratives
What did the dentist see that made him/her decide what treatment was necessary and appropriate?
Is the information obvious on the x-ray?
If not obvious to claim reviewer, send a narrative stating what cannot be seen on the x-ray
Clearly document in your charts
Service not covered By patient’s plan
Plan’s payment criteria not met
Direct patient to Employer Benefits Manager
Send a copy ofdenied EOB
Write “requesting2nd review”
Appealing Denied Claims
Provide narrativewith add’l info
Attach x-ray, Photos, chart notes
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Prompt Payment Requirements
Regulated by state insurance laws?
Prompt payment laws only apply to fully insured plans licensed in the state where the plan is sold
PPO contract require prompt payment?
Provider contract may define carrier’s prompt payment obligation and interest penalty
ERISA/ US Department of Labor
Self-insured dental plans are regulated by the Employee Retirement Income Security Act of 1974
ERISA only requires acknowledgement that claim was received within 45 days
ERISA Prompt Payment Requirements
Q. Does ERISA require dental claims to be paid within a certain number of days?
A. “There is no requirement for claims to be paid within a certain number of days under ERISA.” Lesley Radcliff, US Dept. of Labor
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State Dept. of InsPrompt Payment
Law
Suggest patient complain to
State Ins. Commissioner
Fully Insured Plan
Prompt Payment Requirements
Self-funded Plans
Provider Contract
No Provider Contract
ERISA –Notice of Receipt
within 45 days
Refer to Contract For Plan’s
Timely Payment Obligation
Suggest patient complain to employer
Complain to network rep
Refund Requests
Is the dental plan regulated by state insurance laws? States often have “Right of Recovery” laws
This only applies to plans licensed in state
Statutory time limitations vary state to state Workers Comp and Medicaid refunds are
regulated by state statute
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Refund Requests
Does your PPO contract address refunds?
Provider contracts often define the provider’s responsibilities to refund overpayments
ERISA Refund Requirements Q. Does ERISA define when a dental plan can
require a refund if a payment was made in error?
A. “There are no set guidelines for when a dental plan can require a refund. If the error is not corrected, then the matter must go through the court system.” Lesley Radcliff, US Dept. of Labor
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State Statute or Dept. of Insurance
Right of RecoveryLaw
Check timeframe and consider sending
appeal letter
Fully Insured Plan, Medicaid or
Workers Comp.
Insurance Refund Requests
Self-funded Plans
Provider Contract
No Provider Contract
Don’t send checkSend appeal letter
Courts must decide
Refer to provider’s contract for
refund obligation
Negotiating PPO Fees Don’t assume that carriers will regularly increase
your PPO fees Write a letter or contact your network
representative annually to negotiate fees. If the network is robust, chances are slim that carrier will negotiate. Know the # of providers in your local network.
Target 10 procedures you want fee increased
Know what UCR percentile you have agreed to accept
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Common Coding Questions When is it appropriate to bill D9310?
If a patient has been referred to you for evaluation by another dentist.
What evaluation code should I bill when a patient presents without a referral and the comprehensive evaluation has already been used by another dentist? Any of the evaluation codes that best match
your treatment…typically for a specialist, D0140 is best.
Common Coding Questions Is there a dental code for "alternative restorative treatment"
(ART)?
The revised code D2940 in 2011 for a protective restoration
Direct placement of a temporary restoration intended restorative material to protect tooth and/or tissue form. This procedure may be used to relieve pain, promote healing, or prevent further deterioration. Not to be used for endodontic access closure, or as a base or liner under restoration.
The AAPD's oral health policy on Interim Restorative Treatment can be accessed at: http://www.aapd.org/media/Policies_Guidelines/P_ITR.pdf
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Common Coding Questions
What Code should be used to report an evaluation on a very young child?
Code D0145 — oral evaluation for a patient under three years of age and counseling with primary caregiver
Common Coding Questions How do I report a supernumerary tooth? Permanent teeth: Add +50 to the nearest tooth number The supernumerary near tooth 14 is identified as #64
(see page 90 of the AAPD Coding Manual)
Primary teeth: Add “S” to the nearest tooth number The supernumerary near tooth “C” is identified as “CS”
(see page 90 of the AAPD Coding Manual)
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Common Coding QuestionsWhat age is considered a child versus an adult?
According to the ADA Resolutions, the age of a “child”
Resolved, that when dental plans differentiate coverage based on the child or adult status of the patient, this determination be based on clinical development of the patient’s dentition, and be it further
Resolved, that where administrative constraints of a dental plan preclude the use of clinical development so that chronological age must be used to determine child or adult status, the plan defines a patient as an adult beginning at age 12 with the exclusion of treatment for orthodontics and sealants.
Space maintainers
Report the anchor tooth/teeth
Include narrative to report that space(s) that are being maintained
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Record Keeping and Documentation
Understand importance for complete records
Identify a comprehensive medical/dental history
Accurately chart an initial examination
Diagnose and sequence treatment plans
Determine what adequate radiographs are
Understand role of informed consent
Identify a record and who “owns”it
Become familiar with common coding errors
Questions?