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

Transcription

1 Coding and Payment Guide for Dental Services A comprehensive coding, billing, and reimbursement resource for dental services 2011

2 Contents Introduction...1 Coding Systems... 1 Claim Forms... 2 Contents and Format of This Guide... 2 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 Supplemental Medicare Coverage Documentation An Overview...19 Methods of Documentation General Guidelines for Documentation Fraud and Abuse Claims Processing...27 What to Include on Claims Determining Coverage Preauthorization 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...34 Procedure Codes...45 HCPCS Level I or CPT Codes...45 HCPCS Level II Codes...45 CDT Codes...47 CPT Codes ICD-9-CM Index ICD-9-CM Coding Conventions Coding Neoplasms Manifestation Codes Official ICD-9-CM Guidelines for Coding and Reporting ICD-9-CM Codes Alphabetic Index to External Causes of Injury and Poisoning (E Code) Medicare Official Regulatory Information Ingenix CPT codes only 2010 American Medical Association. All Rights Reserved. iii

3 Introduction Generally, the reason the patient sought treatment should be sequenced first when multiple diagnoses are listed. Many claim forms, with the exception of the ADA dental form, require that the appropriate ICD-9-CM code be reported rather than a description of the functional deficit or defect. Dental providers need to be aware of the necessity for specific diagnosis coding. Using only the first three digits of the ICD-9-CM diagnosis code when fourth and fifth digits are available will result in invalid coding. So will the addition of extraneous fourth and fifth digits when they are not required. On January 16, 2009, The Department of Health and Human Services (HHS) published a final rule making modifications to the Health Information Portability and Accountability Act (HIPAA) code sets standards a change the health care industry had been awaiting. Effective October 1, 2013, the ICD-10-CM code set will be required for reporting diagnoses, and ICD-10-PCS for reporting of inpatient hospital services and surgical procedures. These new codes replace the current International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), volumes 1 and 2, and the ICD-9-CM, volume 3, for diagnosis and procedure codes, respectively. Claims for dates of service after September 30, 2013, must contain ICD-10-CM codes or they will be denied. ICD-10-CM Classification System The current code set for diagnoses and health status indicators in the United States is ICD-9-CM. ICD-9-CM is a modification of the ICD-9 code set as published by the World Health Organization (WHO), which was used prior to 1999 for morbidity reporting. The 10th revision of this classification system, International Classification of Diseases, 10th Revision (ICD-10) has been in use for morbidity reporting since January 1, 1999, in many other countries. The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) is a modification of the WHO s code set for use in claims submission. Although the most recent draft release of ICD-10-CM is readily available for public viewing, ICD-10-CM codes are not valid for any purpose or use at the time of this publication. The Critical Access to Health Information Technology Act of 2007 requires the secretary of Health and Human Services to establish a program to award grants to states to increase access to health care in rural areas by improving health information technology. This act also directs the secretary to promulgate a final rule concerning the replacement of the ICD-9-CM with ICD-10-CM and authorized the secretary to adopt specified standards for recommended electronic health in relation to such replacements. A final rule was published in the January 16, 2009, Federal Register, with adoption of ICD-10-CM and ICD-10-PCS to replace ICD-9-CM, volumes 1, 2, and 3, effective October 1, The ICD-10 is copyrighted and published by the WHO. The United States is bound by international treaty to report mortality data to the WHO using ICD-10 codes. Therefore, the ICD-10-CM is a clinical modification of the WHO s ICD-10 classification. ICD-10-CM is a morbidity classification published by the United States for classifying diagnoses and reasons for visits in all health care settings. ICD-10-CM is a morbidity classification that contains a higher level of data granularity (detail) than is required in a mortality classification such as ICD-9-CM. Since ICD-10-CM is a morbidity classification, no strictly fatal conditions (e.g., decapitation) are Coding and Payment Guide for Dental Services included in the classification. However, classification codes for circumstances such as codes for stillbirth and unattended death are included for situations in which a diagnosis is necessary for reporting. The National Center for Health Statistics (NCHS), one of the Centers for Disease Control and Prevention (CDC), an agency within the United States Department of Health and Human Services (HHS) is responsible for the development and use of ICD-10-CM. Claim Forms Noninstitutional providers and suppliers (private practice or other health care providers offices) use the CMS-1500 form to submit claims to Medicare contractors for Medicare Part B covered services. Medicare Part B coverage provides payment for medical supplies and physician and outpatient services. Other dental payers accept the ADA form as an acceptable billing document for most dental 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. 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. Contents and Format of This Guide Coding 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 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. 2 CPT codes only 2010 American Medical Association. All Rights Reserved Ingenix

4 Procedure Codes D4263-D4264 D4263 D4264 bone replacement graft - first site in quadrant bone replacement graft - each additional site in quadrant Explanation A bone replacement graft is used to replace damaged, atrophic, or excised bone. Incisions are made down through the soft tissue to expose the recipient site for the bone replacement graft and the graft is placed into position. The graft may be packed firmly into position or secured by other methods. The incisions are then sutured closed. Report D4263 for the first site in a quadrant and D4264 for each additional site in the quadrant on the same day of service Other postoperative infection (Use additional code to identify infection) Associated CPT Codes Coding and Payment Guide for Dental Services Augmentation, mandibular body or angle; prosthetic material Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft) IOM References D4263-D ,1,70; 100-2,15,150; 100-2,16,140; 100-3,260.6; 100-4,4,20.5 Coding Tips These codes have been revised for the official CDT description. Local anesthesia is included in these services. Any radiographs are reported separately. Report D4264 in addition to D4263. It cannot be reported alone. Third-party payers may require submission of x-rays or x-ray reports and periodontal charting. Periodontal charting should include the identification of the quadrants and sites involved, a minimum of three pocket measurements per tooth involved, indication of recession, furcation involvement, mobility and mucogingival defects, and identification of missing teeth. Check with payers for their specific requirements. These codes include postoperative care. Terms To Know contour. Act of shaping along desired lines. flap graft. Mass of flesh and skin partially excised from its location but retaining its blood supply, grafted onto another site to repair adjacent or distant defects. ostectomy. Excision of bone. HCPCS Codes A4550 A4649 Surgical trays Surgical supply; miscellaneous ICD-9-CM Diagnostic Codes Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Osseointegration failure of dental implant Post-osseointegration biological failure of dental implant Post-osseointegration mechanical failure of dental implant Inflammatory conditions of jaw Tooth (broken) (fractured) (due to trauma), without mention of complication Tooth (broken) (fractured) (due to trauma), complicated Mechanical complication due to other implant and internal device, not elsewhere classified Infection and inflammatory reaction due to other internal prosthetic device, implant, and graft (Use additional code to identify specified infections) Work Value D D Non-Fac PE Fac PE Malpractice Non-Fac Total Fac Total These CDT RVUs are not developed by CMS. CDT only 2010 American Dental Association. All Rights Reserved Ingenix

5 Coding and Payment Guide for Dental Services Alveoloplasty, each quadrant (specify) Explanation The physician alters the contours of the alveolus by selectively performing alveoloplasty to remove sharp areas or undercuts of alveolar bone. The physician makes incisions in the mucosa overlying the alveolus, exposing the alveolar bone. Drills, osteotomes, or files are used to contour the bone. The mucosa is sutured in place over the contoured bone. Coding Tips Alveoloplasty on the second, third, or fourth quadrant may be reported separately. If gingivoplasty is completed per quadrant during separate sessions, report one quadrant per session. This procedure is for contouring of the alveolus in up to one-half of an upper or lower arch. When is performed with another separately identifiable procedure, the highest dollar value code is listed as the primary procedure and subsequent procedures are appended with modifier 51. Local anesthesia is included in the service. Alveoloplasty may also be reported using codes D7310, D7311, D7320 or D7321. For alveolectomy, see For closure of lacerations, see or For segmental osteotomy, see Terms To Know alveolar process. Bony part of the maxilla or mandible that supports the tooth roots and into which the teeth are implanted. alveolectomy. Partial or total excision of the maxillary or mandibular alveolar process. alveoloplasty. Surgical recontouring of the bone to which a tooth is attached, usually performed prior to the fitting of prosthesis. HCPCS Codes N/A ICD-9-CM Diagnostic Codes Malignant neoplasm of upper gum Malignant neoplasm of lower gum Malignant neoplasm of mandible Secondary malignant neoplasm of other specified sites Benign neoplasm of other and unspecified parts of mouth Benign neoplasm of lower jaw bone Carcinoma in situ of lip, oral cavity, and pharynx Neoplasm of uncertain behavior of lip, oral cavity, and pharynx Neoplasm of uncertain behavior of bone and articular cartilage Acute apical periodontitis of pulpal origin Gingival recession, unspecified Gingival recession, minimal Gingival recession, moderate Gingival recession, severe Gingival recession, localized Gingival recession, generalized Chronic periodontitis, localized Chronic periodontitis, generalized Alveolar mandibular hyperplasia Alveolar mandibular hypoplasia Loss of teeth due to trauma (Code first class of edentulism: , ) Loss of teeth due to periodontal disease (Code first class of edentulism: , ) Loss of teeth due to caries (Code first class of edentulism: , ) Complete edentulism, class II (Use additional code to Complete edentulism, class III (Use additional code to Complete edentulism, class IV (Use additional code to Partial edentulism, class II (Use additional code to Partial edentulism, class III (Use additional code to Partial edentulism, class IV (Use additional code to IOM References ,15,150; 100-4,12,30 Procedure Codes Work Value Non-Fac PE 5.25 Fac PE 2.95 Malpractice 0.45 Non-Fac Total 8.83 Fac Total 6.53 CPT only 2010 American Medical Association. All Rights Reserved Ingenix These CDT RVUs are not developed by CMS. CDT only 2010 American Dental Association. All Rights Reserved. 333