Coding and Payment Guide for Dental Services. A comprehensive coding, billing, and reimbursement resource for dental services - PDF

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Coding and Payment Guide for Dental Services A comprehensive coding, billing, and reimbursement resource for dental services 2016 Contents Introduction...1 Coding Systems... 1 Claim Forms... 2 Contents
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Coding and Payment Guide for Dental Services A comprehensive coding, billing, and reimbursement resource for dental services 2016 Contents Introduction...1 Coding Systems... 1 Claim Forms... 2 Contents and Format of This Guide... 3 The Reimbursement Process...5 Coverage Issues... 5 Payment Methodologies... 6 Modifier Use... 8 Tooth Number and Surface... 8 Other Factors Influencing Payment... 9 Participation in Medicare Plans Documentation An Overview...19 Methods of Documentation General Guidelines for Documentation Principles of Documentation Waste, Fraud, and Abuse Preauthorization...27 Clean Claims...27 The Health Insurance Portability and Accountability Act Processing the Claim...31 Appeals Process...32 Dental Claim Form...33 The CMS-1500 Claim Form...35 Procedure Codes...55 HCPCS Level I or CPT Codes...55 CDT Codes...57 CPT Codes ICD-9-CM Index Alphabetic Index to External Causes of Injury and Poisoning (E Code) Medicare Official Regulatory Information Claims Processing...27 What to Include on Claims Determining Coverage Optum360, LLC CPT 2014 American Medical Association. All Rights Reserved. iii Coding and Payment Guide for Dental Services procedures, including diagnostic, preventive, restorative, endodontal, and periodontal services. CMS-1500 Forms Most Medicare covered dental services are filed using ICD-9-CM diagnosis codes, HCPCS procedure codes (Levels I and II), and CMS-1500 forms. This includes covered services performed as the result of an illness or injury. Because of the need to accommodate ICD-10-CM codes and other ASCI X12 requirements the National Uniform Claim Committee has revised the CMS-1500 claim form. The latest revision or the 02/12 version has been approved by the Office of Management and Budget. At the time of printing however, an effective date for the use of the revised form has not been released. Dental Billing Forms The ADA has created a generic billing form that is used by most dental third-party payers. The ADA Dental Claim Form provides a common format for reporting dental services to a patient s dental benefit plan and has been revised to meet the Health Insurance Privacy and Accountability Act (HIPAA) requirements. ADA policy promotes use and acceptance of the most current version of the ADA Dental Claim Form by dentists and payers. The most current version of the claim also allows reporting of the national provider identifier (NPI). There are significant numbers of claims that are filed using forms customized by the provider. These superbills typically are multipart check-off forms. While these bills improve the efficiency of the provider s office, they may create difficulties in the payer's claims flow and can result in delayed reimbursement. The most recent revisions to this claim form were made in July Contents and Format of This Guide Coding and Payment Guide for Dental Services has three primary sections: reimbursement, definitions and guidelines, and Medicare official regulatory information. Reimbursement The first section of the guide provides comprehensive information about the coding and reimbursement process. It has four chapters: Introduction, The Reimbursement Process, Documentation An Overview, and Claims Processing. Definitions and Guidelines The second section provides the definitions and guidelines for using the 2014 CDT codes, as well as the ICD-9-CM codes that most commonly support medical necessity of the service, any associated HCPCS Level II codes (other than the D codes), CPT codes, and reimbursement information. Procedure Code Definitions and Guidelines This section begins with the standard coding definitions and guidelines for CDT or CPT codes. Following this section is a listing of the most common CDT or CPT codes applicable to dental services. At the top of each page you will find a code or code range with its official description, followed by an explanation of the procedure or supply. Procedure codes are crosswalked to other HCPCS Level II codes, common ICD-9-CM codes, relative value units, and, when applicable, CPT or CDT procedure codes, coding tips, terms to know, pertinent sections from official Medicare manuals, and reference numbers. A listing of official Medicare manual references Introduction completes this section. All this information is designed to allow the user to appropriately code and bill for services. ICD-9-CM Definitions and Guidelines An overview of the ICD-9-CM coding conventions and guidelines is presented in this section. A comprehensive alphabetic index of ICD-9-CM diagnosis codes specific to dental services is in the index at the end of this section. Please note that this list of associated ICD-9-CM codes is not all inclusive. The procedure may be performed for reasons other than those listed that support the medical necessity of the service. Only those conditions supported by the medical record documentation should be reported. A separate ICD-9-CM index lists the E codes commonly associated with the circumstances and conditions that could cause injury to teeth and oral structures and may require dental services. Medicare Official Regulatory Information Full excerpts from applicable Medicare manuals, including the Medicare National Coverage Determinations Manual and the Medicare Benefit Policy Manual applicable to dental services are provided in this section. These excerpts often do not identify the guideline with corresponding HCPCS Level II codes. Our experts have crosswalked the reference, wherever possible, to the appropriate procedure or supply code, so that the reference appears in the main body of the book with the associated codes. The full text of all of the internet-only manuals (IOM) may be found at Manuals/Internet-Only-Manuals-IOMs.html. How to Use This Guide The first three chapters: The Reimbursement Process, Documentation An Overview, and Claims Processing may be read in their entirety and/or used as references. When using this Coding and Payment Guide for code assignment, follow these important steps to improve accuracy and experience fewer overlooked diagnoses and services: Step 1. Carefully read the medical record documentation that describes the patient s diagnosis and the service provided. Remember, more than one diagnosis or service may be documented. Step 2. Locate the appropriate CPT or dental procedure code in the chapter titled Procedure Codes. Read the explanation and determine if that is the procedure performed and supported by the medical record documentation. Step 3. At this time, review the additional information pertinent to the specific code found in the coding tips, IOM references, and the Medicare physician fee schedule references. Use the Terms to Know to help ensure appropriate code assignment. Step 4. Peruse the list of ICD-9-CM codes to determine if the condition documented in the medical record is listed and the code identified. If the condition is not listed refer to the ICD-9-CM index or the ICD-9-CM manual to locate the appropriate code. Assessing the ICD-10-CM Code Crosswalks on October 1, 2015 Optum will include the ICD-9-CM to ICD-10-CM crosswalk in the web-based This 2015 Optum360, LLC CPT 2014 American Medical Association. All Rights Reserved. 3 Procedure Codes D0140-D0145 D0140 limited oral evaluation - problem focused An evaluation limited to a specific oral health problem or complaint. This may require interpretation of information acquired through additional diagnostic procedures. Report additional diagnostic procedures separately. Definitive procedures may be required on the same date as the evaluation. Typically, patients receiving this type of evaluation present with a specific problem and/or dental emergencies, trauma, acute infections, etc. D0145 oral evaluation for a patient under three years of age and counseling with 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 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. Explanation The limited evaluation is problem focused on a particular dental health problem or concern presented by the patient. It includes the interpretation of information acquired through additional, separately-reportable, diagnostic oral health tests. It may lead to the decision that other definitive procedures are also required. Report D0145 when patient is younger than three years and primary caregiver is counseled. Coding Tips Code D0140 reports a type of evaluation typically provided if the patient presents with trauma, acute infection, other oral care emergency, or when the patient has been referred for a specific problem. When an oral health assessment is performed by someone other than the dentist for example, a licensed dental hygienist, some third-party payers may require that modifier DA Oral health assessment by a licensed health professional other than a dentist, be appended to codes D0140 and D0145. Check with third-party payers for their specific requirements. Report code D0160 when a detailed and extensive oral evaluation is provided. When a comprehensive examination is performed, see D0150. When the provider performs a caries risk assessment using a standardized risk assessment tool, see D0601-D0603. Documentation for code D0145 should include oral and physical health history, evaluation of caries susceptibility, and development of appropriate oral health regimen including discussion of said regimen with caregiver. Because of the level of care required by children under the age of 3, code D0145 may be reported for reevaluations if all of the above components are performed and documented. Any radiograph, prophylaxis, fluoride, restorative, or extraction service is reported separately. Terms To Know evaluation. Dynamic process in which the dentist makes clinical judgments based on data gathered during the examination. HCPCS Codes N/A ICD-9-CM Diagnostic Codes V72.2 Coding and Payment Guide for Dental Services Herpetic gingivostomatitis Malignant neoplasm of cheek mucosa Malignant neoplasm of palate, unspecified Benign neoplasm of other and unspecified parts of mouth Carcinoma in situ of lip, oral cavity, and pharynx Supernumerary teeth Disturbances in tooth eruption Dental caries limited to enamel Dental caries extending into dentine Diseases of hard tissues of teeth, abrasion, extending into dentine Diseases of hard tissues of teeth, abrasion, extending into pulp Diseases of hard tissues of teeth, abrasion, localized Diseases of hard tissues of teeth, abrasion, generalized Diseases of hard tissues of teeth, erosion, extending into pulp Cracked tooth Pulpitis Acute apical periodontitis of pulpal origin Radicular cyst of dental pulp Acute gingivitis, plaque induced Acute gingivitis, non-plaque induced Chronic gingivitis, plaque induced Chronic gingivitis, non-plaque induced Aggressive periodontitis, localized Aggressive periodontitis, generalized Acute periodontitis Anomaly of tooth position, unspecified Open restoration margins Fractured dental restorative material without loss of material Fractured dental restorative material with loss of material Stomatitis and mucositis, unspecified Dental examination (Use additional code(s) to identify any special screening examination(s) performed: V73.0-V82.9) Please note that this list of associated ICD-9-CM codes is not all-inclusive. The procedure may be performed for reasons other than those listed that support the medical necessity of the service. Only those conditions supported by the medical record documentation should be reported. Work Value D D Non-Fac PE Fac PE Malpractice Non-Fac Total Fac Total 58 These CDT RVUs are not developed by CMS. CDT 2014 American Dental Association. All Rights Reserved Optum360, LLC Coding and Payment Guide for Dental Services Treatment of superficial wound dehiscence; simple closure with packing Procedure Codes Explanation There has been a breakdown of the healing skin either before or after suture removal. The skin margins have opened. The dentist cleanses the wound with irrigation and antimicrobial solutions. The skin margins may be trimmed to initiate bleeding surfaces. Report if the wound is sutured in a single layer. Report if the wound is left open and packed with gauze strips due to the presence of infection. This allows infection to drain from the wound and the skin closure will be delayed until the infection is resolved. Coding Tips For extensive or complicated secondary wound closure, see For wound closure by tissue adhesive(s) only, see HCPCS Level II code G0168. To report extensive debridement of soft tissue and/or bone, not associated with open fractures and/or dislocations, resulting from penetrating and/or blunt trauma, see Surgical trays, A4550, are not separately reimbursed by Medicare; however, other third-party payers may cover them. Check with the specific payer to determine coverage. When the condition is the result of an accident, the dental insurer may require that the medical insurance be billed first. When covered by the medical insurance, the payer may require that the appropriate CPT code be reported on the CMS-1500 claim form. Terms To Know dehiscence. Complication of healing in which the surgical wound ruptures or bursts open, superficially or through multiple layers. infection. Presence of microorganisms in body tissues that may result in cellular damage. irrigate. Washing out, lavage. packing. Material placed into a cavity or wound, such as gels, gauze, pads, and sponges. HCPCS Codes N/A ICD-9-CM Diagnostic Codes Disruption of wound, unspecified Disruption of external operation (surgical) wound Disruption of traumatic injury wound repair Other postoperative infection (Use additional code to identify infection) Non-healing surgical wound Please note that this list of associated ICD-9-CM codes is not all-inclusive. The procedure may be performed for reasons other than those listed that support the medical necessity of the service. Only those conditions supported by the medical record documentation should be reported. Work Value Non-Fac PE Fac PE Malpractice Non-Fac Total Fac Total Optum360, LLC CPT 2014 American Medical Association. All Rights Reserved. 351
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