ICD Codes in State Medicaid Dental Claims Submission
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1 ICD Codes in State Medicaid Dental Claims Submission Dental Informatics Center for Informatics and Standards Practice Institute September 2015
2 Disclaimer This presentation is for educational purposes only and is not intended to be used as legal or billing advice. If you have legal questions or concerns please consult with your appropriate legal counsel. Dentists should refer to their State Medicaid Websites for more current and complete information on dental claims submission and diagnostic codes requirements American Dental Association, All Rights Reserved 2
3 ICD Reporting in Dental Claims - Rationale Some State Medicaid Programs are requiring diagnostic codes in dental claims submission Rationale Through the ICD reporting, it is hoped that there will be a benefit to the provider/patient over time by improving the tracking of treatment and associated ICD To capture clinical data to support public health activities, development of evidence-based benefits plans and to support efforts for increased funding To facilitate payment for services related to the oral - systemic connection and coverage for additional dental services for certain medical conditions 2015 American Dental Association, All Rights Reserved 3
4 State Medicaids that Require Diagnosis Codes STATE MEDICAID REQUIREMENTS * *Dentists should check their State Medicaid Websites for up to date information and a complete list of requirements. ARIZONA IOWA Diagnosis code(s) required when the patient s underlying medical condition is the reason for the services provided on the claim. V22.2 (Pregnancy) and V49.89 (Disabled) must be reported whenever a patient has either of these conditions, regardless of services provided. Note that Iowa is still accepting the 2006 claim form and there is no cutoff date planned at this time. MAINE MICHIGAN NEVADA VERMONT Diagnosis code required on dental claims for procedure code D4341 for all patients whose diagnosis is ICD-9 code 101 (Acute Necrotizing Ulcerative Gingivitis) or ICD-10 code A69.0 (necrotizing ulcerative stomatitis) or A69.1 (other Vincent s infections). For patients with no ICD-9 code 101 or ICD-10 codes A69.0 or A69.1 diagnosis, claims for this procedure code require Prior Authorization. Diagnosis codes are required for all oral and maxillofacial surgery and/or anesthesiology services New 2012 ADA form with valid diagnosis codes, diagnosis pointers and place of treatment. Will not require reporting of ICD codes until October 1, 2015 at the earliest American Dental Association, All Rights Reserved 4
5 What Does ICD-9-CM Mean? ICD = International Classification of Disease Number indicates the version: Ninth Release CM = Clinical Modification International Classification of Disease, Ninth Release, Clinical Modification 2015 American Dental Association, All Rights Reserved 5
6 Reporting Diagnostic Codes to State Medicaid When Required A dentist must report an appropriate ICD diagnostic code along with the correct CDT code for the service performed The meaning of appropriate in relation to diagnostic codes may vary It must be a valid and current code It should be relevant and specific enough to provide a rationale for the service reported 2015 American Dental Association, All Rights Reserved 6
7 Diagnoses Codes in Medicaid Dental Claims For electronic filing, dentists may be able to use a state Medicaid web portal for dental claims submission The ADA 2012 Dental Claim Form can accommodate ICD diagnostic codes As with dental procedures, codes that are current for the date of service must be used ICD-9-CM codes before October 1, 2015 ICD-10-CM codes on or after October 1, American Dental Association, All Rights Reserved 7
8 2012 ADA Claim Form 2015 American Dental Association, All Rights Reserved 8
9 Completing the 2012 ADA Claim Form Item 34 on the 2012 ADA Dental Claim Form is used to identify the source of diagnosis codes listed in Item 34a ICD-9-CM is the current source of diagnosis codes and is identified by the letter B in Item American Dental Association, All Rights Reserved 9
10 Completing the 2012 ADA Claim Form Before October 1, 2015: Indicate ICD-9-CM in Item 34 by entering B After the ICD-10 CM Transition: On or after October 1, 2015 use of ICD-10 CM for reporting diagnoses is required Indicate ICD-10 CM in Item 34 by entering AB 2015 American Dental Association, All Rights Reserved 10
11 Completing the 2012 ADA Claim Form You should enter the appropriate diagnosis codes for the service you are providing based on the existing ICD-9-CM diagnosis codes A is always the primary diagnosis Item 34a is where up to four diagnosis codes may be entered, with the primary diagnosis code always reported on line A The ADA s comprehensive claim form completion instructions are posted online at Please check with your State Medicaid: they may have additional instructions available on their website 2015 American Dental Association, All Rights Reserved 11
12 The Diagnosis Cross Reference (Pointer) When diagnosis codes are required, another associated field will also be required - the pointer The purpose of pointer (Item 29a) is to associate the procedure with one of four of the diagnosis codes you have listed on Item 34a Enter a letter (A, B, C, or D) to point to a diagnosis entered in item 34a Enter only one pointer per line item When multiple services are performed, enter the primary pointer for each service 2015 American Dental Association, All Rights Reserved 12
13 Dental Procedure Codes (CDT) and ICD-9 CM ADA has developed some tables to associate common CDT procedure codes with likely diagnoses and their suggested ICD-9 CM These examples are not assumed to be complete nor are they prescriptive 2015 American Dental Association, All Rights Reserved 13
14 Tips for Dental Providers Stay alert for State Medicaid communications about diagnostic codes requirements Ensure that the billing systems can support use of diagnostic codes Visit ADA.org and ADA Center for Professional Success and keep current with ADA dental coding reference materials CDT and CDT Companion Educational seminars and materials are also available from a number of sources, possibly including your state and/or local dental societies 2015 American Dental Association, All Rights Reserved 14
15 ADA Dental Coding Reference Materials The CDT Companion publication has extensive ICD coding suggestions for commonly reported CDT coded services 2015 American Dental Association, All Rights Reserved 15
16 Resources ICD-9 CM and ICD-10 CM codes are available for download free of cost from the Centers for Disease Control and Prevention (CDC) website at: and American Dental Association, All Rights Reserved 16
17 Resources American Dental Association Looking up ICD codes Arizona State Medicaid nual/ffs_chap07.pdf. Vermont State Medicaid American Dental Association, All Rights Reserved 17
18 Contact Information Dental Informatics Center for Informatics and Standards ADA Practice Institute American Dental Association 211 East Chicago Avenue Chicago, Illinois American Dental Association, All Rights Reserved 18
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