Insurance Coding: Teaching Our Periodontics Residents
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1 Charleston, SC Insurance Coding: Teaching Our Periodontics Residents Joe W. Krayer, D.D.S., M.S. Associate Professor & Director Post-Doctoral Periodontics Program Robert G. Gellin, D.M.D., M.H.S. Professor and Chair Department of Stomatology Director Pre-Doctoral Periodontics axium / Power Admin / Patient Access / EasyMarkit Administrator September 30, 2013
2 Objectives Our goals and expectations of the residents Our approach to teaching CDT insurance codes Describing and understanding the appropriate uses of the codes we teach How axium contributes to the educational process Understanding the use and benefits of organized quick lists in axium How to setup and use macro insurance codes in axium
3 Insurance Coding: What do students learn in Pre-Doctoral Programs? The results of an informal survey minimal insight into coding What did they learn? Some procedural codes, but no real understanding of the codes Familiar codes (D Adult Prophy, D Periodic Oral Evaluation, D0210 Complete Series of Radiographs) Rarely any understanding of the differences between codes such as D1110 and D4910
4 Our Goal With Our Residents Reach an understanding of which codes should be chosen for specific patient visits. Reach an understanding of which codes must be bundled for complex treatments such as periodontal flap surgery, particulate graft, regenerative biologic, membrane. Become comfortable using the axium software choosing procedure codes.
5 Our Goal With Our Residents Gain an understanding of how these insurance codes are developed, maintained, changed and the importance of remaining current with the code structure. Become comfortable consulting the CDT publication as a reference for these insurance coding issues. Consider the experiential information many of our faculty members bring from their private practices in the arena of claims filing, educating patients about insurance and the intricacies of dealing with insurance carriers.
6 What We Don t Expect of Our Residents Memorize the entire CDT publication. Complete patient visits without using the CDT or information embedded in axium by our administrator.
7 One MUST Stay Current With CDT Codes! We have this book, but codes are not in effect until January 1, 2014
8 CDT Books Come With a CD These are PDF s
9 CDT Companion Coding exercises and discussion on how to use codes appropriately Diagrams Flow Chart
10 CDT Companion
11 Our Approach Show the residents how the codes are accessed in axium. Discuss the most recent CDT publication available at the time of the new first-year residents orientation period. Consider, in detail, the sections of the CDT that will apply most often to the residents anticipated experiences.
12 The Most Recent Available CDT For this group of residents who began our program July 1, 2013, we are using the CDT We ordered the CDT-2014 from the ADA two days before the presentation with our residents this year. We explain the CDT as a reference tool. We stress that the ADA owns the CDT publication. We demonstrate how much the CDT must cover and how many of the sections will not apply to most of our patient visits.
13 The Most Recent Available CDT As an attempt to edit the information in the CDT to the information we feel is most applicable, we DO NOT cover: D2000 D2999 Most of the restorative procedures D5900 D5999 Most of the maxillofacial prosthetic procedures D8000 D8999 Most of the orthodontic procedures
14 As an attempt to edit the information in the CDT to the information we feel is most applicable, we DO cover in detail: D0100 D0999 Most of the diagnostic procedures D1000 D1999 Some of the preventive procedures D3000 D3999 Some of the endodontic procedures D4000 D4999 All of the periodontics procedures D6000 D6199 D7000 D7999 D9000 D9999 Many of the implant procedures but not all the restorative aspect codes Some of the oral and maxillofacial surgery procedures Most of the adjunctive procedures including medicament administration, sedation procedures and occlusion therapies
15 Diagnostic Codes (Codes D0100 D0999) Differentiation of the examination codes: D0120 Periodic oral evaluation, established patient D0140 Limited oral evaluation, problem focused D0150 Comprehensive oral evaluation, new or established patient D0180 Comprehensive periodontal evaluation, new or established patient
16 Radiograph codes: Diagnostic Codes (Codes D0100 D0999) When is a radiograph a part of a procedure and thus a no-charge event? When is a follow-up radiograph a no-charge event? Stress we have ALL our CBCT studies interpreted by our radiologist to avoid Any question of completeness of the interpretation
17 D1110 D4910 D4355 Preventive Procedures (Codes D1000 D1999) Adult Prophy Periodontal Maintenance Full Mouth Debridement How do you explain these to the patient? My insurance covers two cleanings per year.
18 Endodontic Procedures (Codes D3000 D3999) Some are applicable: D3450 Root Amputation D3920 Hemisection BOTH include removal of the root; there is not an additional charge for an extraction Any attempt at socket preservation or ridge augmentation is a new charge
19 Periodontics Procedures (Codes D D4999) Codes with definitions of extent of procedure: D4210 / D4211 Gingivectomy D4240 / D4241 Gingival Flap D4260 / D4261 Flap and Osseous Surgery D4230 / D4231 Anatomic Crown Exposure Documentation for code chosen?
20 Extent of Procedure Site: A term used to describe a single area, position, or locus. The word site is frequently used to indicate an area of soft tissue recession on a single tooth or an osseous defect adjacent to a single tooth; also used to indicate soft tissue defects and/or osseous defects in edentulous tooth positions. CDT-2013 page 29
21 Extent of Procedure If two contiguous teeth have areas of soft tissue recession, each area of recession is a single site. If two contiguous teeth have adjacent but separate osseous defects, each defect is a single site. If two contigous teeth have a communicating interproximal osseous defect, it should be considered a single site. CDT-2013 page 29
22 Extent of Procedure All non-communicating osseous defects are single sites. All edentulous non-contiguous tooth positions are single sites. Depending on the dimensions of the defect, up to two contiguous edentulous tooth positions may be considered a single site. CDT page 29
23 Periodontics Procedures (Codes D D4999) Codes for procedures that seem similar but are not D4240 / D4241 Gingival Flap D4260 / D4261 Flap and Osseous Surgery D4245 Apically Positioned Flap What is the difference when choosing the code?
24 Periodontics Procedures (Codes D D4999) Codes for procedures that seem similar but are not D4230 / D4231 Anatomic Crown Exposure D4249 Crown Lengthening Surgery What is the difference when choosing the code? Restorative?
25 Periodontics Procedures (Codes D D4999) Codes for nonsurgical therapies D4341/D4342 D4355 Scaling and Root Planing Full Mouth Debridement to Enable Comprehensive Evaluation and Diagnosis How will you or should you combine any of these with D1110 Adult Prophy?
26 Periodontics Procedures (Codes D D4999) Codes for regenerative therapies - Membrane Assisted D4266 (resorbable per site); D4267 (nonresorbable per site and includes removal of membrane) How many membranes are available in your clinic? How do you manage the dramatically variable costs to you for the membrane?
27 Periodontics Procedures (Codes D4000 D4999) Codes for regenerative therapies D4265 Biologics How many do you utilize? Emdogain; GEM-21; rhbmp-2 How do you manage the dramatically different costs to you of these materials?
28 Periodontics Procedures (Codes D4000 D4999) Codes for regenerative therapies D4263/D4264 Particulate Grafts How many do you have available: demineralized, mineralized freeze dried bone allograft; hydroxyapatite; BioOss; beta-tricaclium phosphate; calcium sulfate What do you do about autogenous grafting? Charge? No Charge?
29 Periodontics Procedures (Codes D4000 D4999) Codes for periodontal plastic surgeries It s not D4271 anymore for a gingival graft- now D4277/D4278 includes the donor site (for tooth and ridge) D4273 Subepithelial Connective Tissue Graft procedure D4276 Connective Tissue Graft with Double Papilla Flap D4275 Soft Tissue Allograft- augment gingiva with or without root coverage; no donor site
30 Biopsies Oral and Maxillofacial Surgery Procedures (Codes D7000 D7999) D7286 Soft tissue D7285 Hard tissue D7288 Brush biopsy D7287 Exfoliative cytology
31 Oral and Maxillofacial Surgery Procedures (Codes D7000 D7999) Orthodontics Related Procedures D7291 Transseptal Fiberotomy/Supracrestal Fiberotomy D7292/D7293/D7294 Temporary Anchorage Devices: plate; screw with surgical flap; screw with no surgical flap D7960/D7963 Frenectomy (frenulectomy)/frenuloplasty
32 Oral and Maxillofacial Surgery Procedures (Codes D7000 D7999) Repair Procedures D7951 Sinus augmentation with bone or bone substitutes via a lateral approach; includes any particulate graft materials; does NOT include any barrier membrane(s) D7952 Sinus augmentation via a vertical approach (Internal Sinus Lift); includes any particulate graft materials
33 Repair Procedures Oral and Maxillofacial Surgery Procedures (Codes D7000 D7999) D7953 Bone Replacement Graft for Ridge Preservation; includes any particulate graft materials; does NOT include any barrier membrane(s); socket graft procedure; does NOT include the extraction
34 Repair Procedures Oral and Maxillofacial Surgery Procedures (Codes D7000 D7999) D7950 Osseous, osteoperiosteal, or cartilage graft of the maxilla or mandible autogenous or nonautogenous; our block graft procedures; includes obtaining an autogenous graft and/or allograft materials; does NOT include any barrier membrane(s)
35 Repair Procedures Oral and Maxillofacial Surgery Procedures (Codes D7000 D7999) D7955 Repair of maxillofacial soft and/or hard tissue defect; This procedure does not include edentulous maxilla and mandibular reconstruction for prosthetic considerations (congenital and traumatic). That is D7950.
36 Adjunctive Procedures (Codes D9000 D9999) D9210/D9211/D9212 Diagnostic Block Anesthesia and Pain Management D9120 Sectioning a fixed partial denture yes there is a code to help recoup the cost of those multiple burs for sectioning a bridge D9110 Palliative (emergency) treatment of dental pain
37 Sedation Adjunctive Procedures (Codes D9000 D9999) D9230 Inhalation Nitrous Oxide Oxygen Sedation D9248 Oral (Enteral) Sedation D9241/D9242 Intravenous (Parenteral) first 30 minutes; each additional 15 minutes
38 Occlusion Adjunctive Procedures (Codes D9000 D9999) D9940 Occlusal Guard D9950 Occlusal Analysis; mounted case D9951 Occlusal Adjustment: limited D9952 Occlusal Adjustment: complete
39 Adjunctive Procedures (Codes D9000 D9999) Administration of Medicaments: Obviously other than local anesthetics for the procedures Oral medication for prophylactic antibiotic coverage Intravenous medication for prophylactic antibiotic coverage Pain medication
40 Adjunctive Procedures (Codes D9000 D9999) Administration of Medicaments: D9610 Parenteral, single administration D9612 Parenteral, two or more administrations D9630 Other drugs and/or medicaments, by report: includes but is not limited to oral antibiotics, oral analgesics and topical fluoride dispensed in the office for home use
41 Implant Procedures (Codes ) Implant Placement D6190 Radiographic/surgical implant index D6010 Surgical placement of implant body; includes second stage surgery if needed and healing cap D6104 Bone Graft at Time of Implant Placement; barrier membrane(s) and/or biologic materials, if used, are reported separately
42 Implant Procedures (Codes ) Implant Placement D6012 Surgical placement of interim implant body for transitional prosthesis; includes removal later D6100 Implant Removal; requires a report/narrative; does NOT include any treatment of the resulting socket/extraction site (D7953)
43 Implant Procedures (Codes ) D6101 Debridement of a periimplant defect and surface cleaning of the exposed implant surfaces, including flap entry and closure D6102 Debridement and osseous contouring of a periimplant defect and surface cleaning of the exposed implant surfaces, including flap entry and closure D6103 Bone graft for repair of periimplant defect; does NOT include flap entry and closure OR barrier membrane(s) and/or biologics
44 Implant Procedures (Codes ) D6080 Implant Maintenance including removal of prosthesis, cleansing of prosthesis and abutments and reinsertion of prosthesis. includes a prophylaxis to provide active debriding of the implant and examination of all aspects of the implant system, including the occlusion and stability of the superstructure. The patient is also instructed in thorough daily cleansing of the implant.
45 Implant Procedures (Codes ) D6080 Implant Maintenance Is this separate from a D1110 in a patient with both natural teeth and implants? Is this separate from a D4910 in a patient with a history of periodontal therapy?
46 How does axium contribute to the educational process?
47 Comments & My Disclaimer As a Periodontist, clinician and axium administrator, I have a unique perspective on the software setup, functionality and use. 80% of U.S. dental schools use axium. For those not using axium, I hope that your software has similar features. This presentation serves as a resource for you and your axium administrator Disclaimer: I do not receive compensation from the Exan Group (axium)
48 Electronic Health Record Accessing the Chart Add tab Click the black arrow facing to the left Click on the folder with the green + sign to create a new record
49 Chart Add tab opens to the Quick List tab Totally customizable by each institution! Provides for the best educational opportunity Provides a mechanism to create categories of treatment
50 Full List Sorting is NOT Customizable and is in CDT Number Order Includes ADA CDT and institution codes in traditional categories
51 Full List opens to this collapsed view Expands to this view
52 Search can be by DESCRIPTION or CODE If searching, the most common method is by description How do I search for the code for a Subepithelial Connective Tissue Graft?
53 Search opens to All Categories Start by clicking on Periodontics, which limits search to the D4000 codes!
54 Type graft in the criteria field Click Search Double click to insert
55 Quick List can open to an expanded view Collapsed view is my preferred choice Collapsed View Must have axium 5.1 or higher
56 Alphabetical order of Quick List headers for our Periodontics residents Makes it VERY easy to find codes!
57 Examples
58 Originally I created individual procedure headers, then placed the ADA CDT codes underneath the header But, there is a better way. Procedure Macros! Looks like a pitch fork
59 What is a Procedure Macro Code? In one line item are 2 or more embedded ADA CDT codes During planning or completion, codes can be added or deleted
60 How Do I Create A Procedure Macro Code? Light bulb to clear data Type new code & description Login as axium administrator Maintenance Clinical tab Procedure Macro Codes Maintenance RAUG10M Ridge Augment, 10mm J-Block Review Macro procedure codes at time of entry
61 Looks complicated How long does is really take to CREATE a macro? Video
62 Looks complicated How long does is really take to ADD the macro to the Quick List? Video
63 How Do I Use A Macro Code? Electronic Health Record Black triangle Folder green + sign
64 Chart Add tab opens Category = Periodontics Hover over Sinus lift, external (lateral) - Displays all codes in the macro This also works in the Treatment Planning module
65 Click the to plan all the procedures in the macro
66 Click OK if there are no changes to the planned procedures
67 Any procedure can be selected and deleted D0330E selected click folder with red X to delete it
68 Click the ellipsis box to add a D0220E procedure Double click the procedure to be added Select the appropriate category and header
69 Click folder with green + sign to add D0220E to the other three codes
70 Click OK to add all four procedures codes at the same time
71 Click OK once more Click UL for the upper left quadrant Click OK All four codes have been planned
72 Video Demonstrating How To Use An axium Macro Code
73
74 Medical University of South Carolina College of Dental Medicine Department of Stomatology Division of Periodontics 173 Ashley Avenue, BSB 119, MSC 507 Charleston, South Carolina Contact Information Joe Krayer Bob Gellin (843) (843) Thank You
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