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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)


Review by AAPD Important Annual Review starting in 2013

Submit completed form to AAPD staff

Council can suggest wording to improve chance of passage


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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


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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.


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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Questions about accuracy?

Use CDT Manual as your guide

Ask dentist who performed the service


Contact Mary Essling at 312-337-2169 or email [email protected]

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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


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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.


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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.


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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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.


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)



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



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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)



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



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Dental

Labial Frenotomy

CDT code D7960 — frenulectomy

Ankyloglossial/tongue tie

CDT code D7960 — frenulectomy



Determine medical necessity

Understand coverage guidelines of patient’s medical policy

Base each decision individually



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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)



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.


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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.


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.


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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.


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.


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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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Evidenced Based Dentistry

Disease Risk Assessment

Caries

Periodontal Disease

Focus on preventive over restorative

Review and reimburse based on treatment success vs. failure rate


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.


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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.


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


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.


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


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?

Documents

Coding and Insurance WorkshopCSPD.April.2013.pptarchive.cspd.org/pdf/2013/AAPD-Coding-and-Insurance-Workshop-Es… · therapy or cracked tooth syndrome. This is not to be used as