QUESTION: Now that 2014 medical plans include preventive dental coverage for children, our office is frustrated trying to understand billing. If a patient has separate dental coverage from medical but their medical also has the preventive dental coverage, which insurance is prime? In addition to all of the other information we need to gather from a patient, if it's a pedo patient, then we now need to get their medical plan information. We’re finding that it is practically impossible to get information on a medical plan's fees/coverage since we're a dental office.
Most of the medical plans have such high deductibles (some preventive counts toward it, some doesn't) that a patient doesn't really get much of a dental benefit until they reach their high deductible. Nonetheless, am I correct in thinking we still have to bill all pedo preventive dental charges to their medical plans because the medical plans need to know that their patient is paying out of pocket?
It seems like the bottom line is —— we get to double our front office work by billing/coordinating with medical plans for preventive pedo, the claims will most likely not get paid until the almost impossible deductible is met, but to help meet the deductible we still need to bill all preventive pedo dental. It seems like a catch 22. It’s a lot of extra paperwork, with no real extra benefits paid in most cases. Am I missing something?
ANSWER FROM CHRISTINE TAXIN, founder and president of Links2Success:
Dental billing has changed and we must change with it. An example of the changes is on the new claim form. The use of the two new codes from last year need to be checked in the box that has EPSDTP.
They are D0190 Screening of patient: A screening, including state or federally mandated screening, to determine an individual’s need to be seen by a dentist for diagnosis. This can be done by mid-level provider, hygienist, medical or dental professional, or nurse, who are acting within the scope of their state licenses.
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 adiagnosis and treatment.
An oral assessment includes a review and documentation of the patient’s medical and dental history, a limited clinical examination (recording of dental restorations and conditions that should be called to the attention of a dentist), and collection of other oral health data to assist in the development of a professional treatment plan if a referral to a dentist for diagnoisis and treatment is necessary.
If your young patients are covered under dental, continue to use dental for billing. The exam, X-rays, cleaning, and flouride should be covered for them at 100%. However, if they have no dental bill, medical for the same treatment using the following codes should also be covered at 100% with no deductable.
When billing medical, I suggest calling them first to get the required information needed for billing. This process is what we have always used for dental with just a few different questions. See Verification form.
99201 New patient problem focused exam
99202 New patient expanded problem focused exam
99203 New patient detailed problem focused exam
99211 Established patient problem focused exam
99212 Established patient expanded problem focused exam
99213 Established patient detailed problem focused exam
99241 Consultation, problem focused
99242 Consultation, expanded problem focused
99243 Consultation, detailed problem focused
70320 Full mouth series
70300 Radiograph tooth, single view
70310 Radiograph teeth, less than full mouth
If the code is not cross coded use the dental or unspecified and write in line 19 on medical claim form what the treatment is. These are a few of the diagnosis codes that can be used. There are also many other codes that should be used when billing. The use of diagnostic codes must be highest to lowest.
520.1 Supernumerary teeth
520.2 Abnormalities of size and form
520.3 Mottled teeth
520.4 Disturbances of tooth formation
520.5 Hereditary disturbances in tooth structure (e.g. Amelogenisis imperfecta)
520.6 Disturbances of tooth eruption
520.7 Teething syndrome
520.9 other specified disorders of tooth development or eruption
521.03 Dental caries, extending into pulp
521.13 Excessive attrition, extending into pulp
521.13 Abrasion, extending into pulp
521.33 Erosion, extending into pulp
521.6 Ankylosis of teeth
522.1 Necrosis of pulp
522.5 Periapical abscess w/out sinus
522.6 Chronic apical periodontitis
522.7 Periapical abscess with sinus
524.19 Anomaly of jaw to cranial base, other specified
524.30 Unspecified anomalies of tooth; diastema, displacement, transposition
524.33 Tipping of teeth, horizontal displacement of teeth
524.35 Rotation of tooth/teeth
524.39 Other anomalies of tooth position
525.11 Loss of teeth due to trauma
525.63 Fractured dental restorative material without loss of material
525.64 Fractured dental restorative material with loss of material
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