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AAPD Coding and Insurance Workshop Mary Essling AAPD 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 1 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 2 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 3 Code Revision Process 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 4 CDT 2013 Changes 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. 5 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 Subsubcategories 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 6 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 patient A 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. 7 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: As revised: D1206 — topical fluoride varnish: therapeutic application for moderate to high caries risk patients D1206 — topical application of fluoride varnish Application of topical fluoride varnish, delivered in a single visit and involving the entire oral cavity. Not to be used for desensitization. Why? No reason why varnish application should be constrained by level of caries risk. 8 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 Restorative Highlighting 2 revisions • D2990 — resin infiltration of incipient smooth surface lesions Placement of an infiltrating resin restoration for strengthening, stabilizing and/or limiting the progression of the lesion. • D2929 — prefabricated porcelain/ceramic crown – primary tooth 9 Restorative Highlighting 2 revisions 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 10 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 11 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 12 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) 13 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 14 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 15 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 thirdparty 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 16 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 17 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 18 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 noncarious 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. 19 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. 20 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 21 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 22 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 D0120 Payer may be bundling 23 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 24 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] 25 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 pxs because plan design defines child up to age 15 Payer is asking you to miscode 26 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 27 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 28 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. 29 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 30 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 precooperative 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 ionomer materials and is not considered temporary. KEY REVISIONS FOR 2011/2012 Revise Subcategory Title Apexification/Recalcification and Pulpal Regeneration Procedures 31 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.) KEY REVISIONS FOR 2011/2012 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. 32 KEY REVISIONS FOR 2011/2012 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 33 KEY REVISIONS FOR 2011/2012 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. FRENOTOMIES/FRENULOPLASTIES When 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 34 FRENOTOMIES/FRENULOPLASTIES When appropriate to bill Medical or Dental Insurance? 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/FRENULOPLASTIES When 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 35 FRENOTOMIES/FRENULOPLASTIES When appropriate to bill Medical or Dental Insurance? 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/FRENULOPLASTIES When 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 36 FRENOTOMIES/FRENULOPLASTIES When appropriate to bill Medical or Dental Insurance? Dental Labial Frenotomy CDT code D7960 — frenulectomy Ankyloglossial/tongue tie CDT code D7960 — frenulectomy FRENOTOMIES/FRENULOPLASTIES When appropriate to bill Medical or Dental Insurance? Determine medical necessity Understand coverage guidelines of patient’s medical policy Base each decision individually 37 KEY REVISIONS FOR 2011/2012 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. 38 KEY REVISIONS FOR 2009/2010 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 tooth with pulp exposure due to caries or trauma Only remove the infected part of the pulp from the pulp chamber (partial pulpotomy) Goal = develop a root end (apex) to avoid apexification 39 Pulpotomy D3220 (Primary) Primary tooth with caries into the pulp Goal: To retain tooth vitality until tooth exfoliates Remove all pulp from the pulp chamber Pulpotomy D3220 (Permanent) Permanent tooth with caries into the pulp Goal: To buy time until patient is able to proceed with RCT Remove all pulp from the pulp chamber 40 Apexification–D3351-D3353 Permanent tooth root will never mature due to caries or trauma Goal: To save the tooth Develop a calcified barrier at root end and complete root canal KEY REVISIONS FOR 2009/2010 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. 41 KEY REVISIONS FOR 2009/2010 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. 42 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 43 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 44 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. Cost Benefits of Preventive Dentistry 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. 45 Cost Benefits of Preventive Dentistry 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 46 Guideline on Caries Risk Assessment and Management 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. 47 Guideline on Caries Risk Assessment and Management 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 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 48 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 49 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. 50 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 51 Fluoride Varnish It is concentrated: 5% NaF in a resin base. It can be used as a topical fluoride, especially in precooperative 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 52 New Product ICON 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 Product Pre-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. 53 The Dental Home A professional environment where a child’s oral health care is delivered in a comprehensive, continuously accessible, coordinated and familycentered 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. 54 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 55 D0145 Appropriate 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 56 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 57 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 58 Administrative Challenges Administrative Challenges Appealing denied claims Prompt payment laws Overpayment refund requests Fees Coordination of benefits 59 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 60 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 Appealing Denied Claims Service not covered By patient’s plan Plan’s payment criteria not met Send a copy of denied EOB Direct patient to Employer Benefits Manager Write “requesting 2nd review” Provide narrative with add’l info Attach x-ray, Photos, chart notes 61 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 62 Prompt Payment Requirements Fully Insured Plan State Dept. of Ins Prompt Payment Law Suggest patient complain to State Ins. Commissioner Self-funded Plans No Provider Contract 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 63 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 64 Insurance Refund Requests Fully Insured Plan, Medicaid or Workers Comp. State Statute or Dept. of Insurance Right of Recovery Law Check timeframe and consider sending appeal letter Self-funded Plans No Provider Contract Don’t send check Send appeal letter Courts must decide Provider Contract 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 65 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 66 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) 67 Common Coding Questions What 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 68 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? 69