Basic Dental Insurance Coding and Billing

Dental plans do not pay for care rendered to patients who are not eligible to receive benefits. Dental plans do not pay for care rendered to patients who are not eligible to receive benefits. When a subscriber starts a new job, there is usually a 30 – 60 day waiting period before coverage becomes effective. When a subscriber starts a new job, there is usually a 30 – 60 day waiting period before coverage becomes effective.

If the subscriber changes jobs, is laid off, or retires, his / her coverage is usually terminated within 30 days of the change in employment. If the subscriber changes jobs, is laid off, or retires, his / her coverage is usually terminated within 30 days of the change in employment. COBRA COBRA The rules for eligibility under other gov’t programs, such as Medicare and CHAMPUS, vary greatly. The rules for eligibility under other gov’t programs, such as Medicare and CHAMPUS, vary greatly.

The dental office should ALWAYS contact the insurance carrier to verify benefits The dental office should ALWAYS contact the insurance carrier to verify benefits BEFORE services are rendered. There is no dental coverage under Medicare ! There is no dental coverage under Medicare !

Coverage can change month to month for some individuals, so it is important to verify benefits before each visit. Coverage can change month to month for some individuals, so it is important to verify benefits before each visit. Know how to read the insurance card ! Know how to read the insurance card ! They are all different ! Sometimes medical card includes dental; sometimes patient has separate cards. They are all different ! Sometimes medical card includes dental; sometimes patient has separate cards.

EMPLOYER – buys the coverage as a benefit for the employees, and negotiates the limitations and benefits of the plan. EMPLOYER – buys the coverage as a benefit for the employees, and negotiates the limitations and benefits of the plan. CARRIER – is responsible for covering only the level of treatment that is included in the plan purchased. CARRIER – is responsible for covering only the level of treatment that is included in the plan purchased.

Information explaining the coverage under a specific plan is found in the benefits booklet that is supplied to the subscriber (employee). Information explaining the coverage under a specific plan is found in the benefits booklet that is supplied to the subscriber (employee). Ask the patient to bring their benefits book to the first dental visit so coverage can be reviewed. Ask the patient to bring their benefits book to the first dental visit so coverage can be reviewed. ! !

LEAT – Least Expensive Alternative Treatment LEAT – Least Expensive Alternative Treatment This is a limitation in a dental plan that allows benefits only for the least expensive treatment.

For Example : The patient needs a replacement for a missing tooth. The treatment choices are a fixed bridge for $ or a removable partial denture for $ Under the LEAT rule, the carrier will pay benefits only for the partial denture. The patient needs a replacement for a missing tooth. The treatment choices are a fixed bridge for $ or a removable partial denture for $ Under the LEAT rule, the carrier will pay benefits only for the partial denture. The patient may have the bridge done but the carrier will only pay the $ The patient must make up the difference. The patient may have the bridge done but the carrier will only pay the $ The patient must make up the difference.

Dual Coverage Dual coverage is when a patient has dental insurance coverage under more than one plan. Dual coverage is when a patient has dental insurance coverage under more than one plan. When this is the case, it is necessary to take steps to be sure that the correct benefits are paid. When this is the case, it is necessary to take steps to be sure that the correct benefits are paid.

When there is dual coverage you must determine which carrier is primary and which is secondary. When there is dual coverage you must determine which carrier is primary and which is secondary. There are specific questions on a claim form that ask for this information. There are specific questions on a claim form that ask for this information.

Coordination of Benefits Husband & Wife both have dental insurance coverage for each other Husband & Wife both have dental insurance coverage for each other If wife is patient, her insurance is primary and her husband’s insurance is secondary. If wife is patient, her insurance is primary and her husband’s insurance is secondary. If husband is patient, his insurance is primary and his wife’s insurance is secondary. If husband is patient, his insurance is primary and his wife’s insurance is secondary.

Birthday Rule If child has insurance coverage from both mom and dad, you use the birthday rule to determine who’s insurance is billed primary, and who’s insurance is billed secondary. If child has insurance coverage from both mom and dad, you use the birthday rule to determine who’s insurance is billed primary, and who’s insurance is billed secondary.

Birthday Rule cont’ Mother’s Birthday Mother’s Birthday April 23, 1968 April 23, 1968 Father’s Birthday Father’s Birthday February 9, 1968 February 9, 1968 Who’s insurance is primary ?

Terminology Usual, Customary, and Reasonable (UCR) Usual, Customary, and Reasonable (UCR) Schedule of Benefits Schedule of Benefits Fixed Fees Fixed Fees Coinsurance / Copayment Coinsurance / Copayment Deductible Deductible

Deductible Individual Deductible – each covered family member must meet this amount in covered services before the insurance will start paying. Individual Deductible – each covered family member must meet this amount in covered services before the insurance will start paying. Family Deductible – total amount of covered services to be paid by family before the insurance will start paying. Family Deductible – total amount of covered services to be paid by family before the insurance will start paying.

Dependent: A child or spouse of the subscriber. Dependent: A child or spouse of the subscriber. Eligibility: The process of determining whether the patient is eligible for benefits. Eligibility: The process of determining whether the patient is eligible for benefits. Exclusions: Services not covered by the dental policy. Exclusions: Services not covered by the dental policy.

Maximum: The maximum dollar amount a benefits plan will pay toward the cost of dental care over a specific period of time (usually one calendar year) Maximum: The maximum dollar amount a benefits plan will pay toward the cost of dental care over a specific period of time (usually one calendar year) Predetermination of Benefits: Also known as a pretreatment estimate, is an admin procedure that may require the dentist to submit a treatment plan to the insurance company before treatment begins. Predetermination of Benefits: Also known as a pretreatment estimate, is an admin procedure that may require the dentist to submit a treatment plan to the insurance company before treatment begins.

Dental Coding Developed by the American Dental Association Developed by the American Dental Association CDT CDT CDT CDT CDT CDT-32000

CDT Categories I. Diagnostic I. Diagnostic D0100 – D0999 D0100 – D0999 II. Preventive II. Preventive D1000 – D1999 D1000 – D1999 III. Restorative III. Restorative D2000 – D2999 D2000 – D2999 IV. Endodontics IV. Endodontics D3000 – D3999 D3000 – D3999

V. Periodontics D4000 – D4999 D4000 – D4999 VI. Prosthodontics, Removable D5000 – D5899 D5000 – D5899 VII. Maxillofacial Prosthetics D5900 – D5999 D5900 – D5999 VIII. Implant Services D6000 – D6199 D6000 – D6199

IX. Prosthodontics, fixed D6200 – D6999 D6200 – D6999 X. Oral Surgery D7000 – D7999 D7000 – D7999 XI. Orthodontics D8000 – D8999 D8000 – D8999 XII. Adjunctive General Services D9000 – D9999 D9000 – D9999

CDT Explanations Each code consists of five digits Each code consists of five digits The first digit is always a D which indicates that this is a dental procedure The first digit is always a D which indicates that this is a dental procedure The 2 nd digit is a number that indicates the category of dental service (I – XII) The 2 nd digit is a number that indicates the category of dental service (I – XII) The remaining numbers indicate specific services within each group The remaining numbers indicate specific services within each group _ _ 999 indicates an “unspecified code” _ _ 999 indicates an “unspecified code”

Example: Code D2150 Dindicates that this is a dental procedure Dindicates that this is a dental procedure 2indicates that this is a restorative procedure 2indicates that this is a restorative procedure 1indicates that this is an amalgam restoration 1indicates that this is an amalgam restoration 5 & 0provide details about the type of restoration 5 & 0provide details about the type of restoration

Coding In A Dental Office Dental insurance has yearly limitations on most policies. Dental insurance has yearly limitations on most policies. For complex procedures, the dental office should research what part of the procedure might be covered by medical insurance to save the dental benefits. For complex procedures, the dental office should research what part of the procedure might be covered by medical insurance to save the dental benefits.

Coding In A Dental Office A nifty way of thinking is to consider the dental benefits as a “gift card.” A nifty way of thinking is to consider the dental benefits as a “gift card.”

Coding In A Dental Office Plan the dental procedure and research any CPT codes that may apply to the procedure. Plan the dental procedure and research any CPT codes that may apply to the procedure. Place a call to the provider hotline for the patient’s medical insurance and inquire as to what would be covered under the medical plan. Place a call to the provider hotline for the patient’s medical insurance and inquire as to what would be covered under the medical plan.

Coding In A Dental Office As an example: United Healthcare’s clinical guidelines cover. As an example: United Healthcare’s clinical guidelines cover. A. Dental trauma due to accidents A. Dental trauma due to accidents B. Cancer B. Cancer C. Cleft Palate C. Cleft Palate D. Transplant preparation D. Transplant preparation E. Systemic Infections E. Systemic Infections

Coding In A Dental Office First: Use the ICD-9 (ICD-10) code for the class of edentulism: First: Use the ICD-9 (ICD-10) code for the class of edentulism: Second: Use an ICD-9 (ICD-10) code for how the teeth were lost: Second: Use an ICD-9 (ICD-10) code for how the teeth were lost: -Accident -Accident -Trauma -Trauma - CA - CA

Coding In A Dental Office Use the E codes to explain the “how” and “where” an accident or trauma happened. Use the E codes to explain the “how” and “where” an accident or trauma happened. Example: Billy Jones lost teeth # 8,9 when he was hit in the mouth with a bat at a baseball game in the park. Example: Billy Jones lost teeth # 8,9 when he was hit in the mouth with a bat at a baseball game in the park.

Coding In A Dental Office Some things to remember: Some things to remember: When coding for implants and billing to the medical insurance, all implants have a 90-day global period, so any office visits postoperatively in that period are billed with When coding for implants and billing to the medical insurance, all implants have a 90-day global period, so any office visits postoperatively in that period are billed with

Coding In A Dental Office Some medical insurance plans will allow you to bill for the removal of implants Some medical insurance plans will allow you to bill for the removal of implants 20670—Removal of superficial implants 20670—Removal of superficial implants 20680—Removal of deep implants 20680—Removal of deep implants

Dental Scheduling Dental Appointments are scheduled in units of time. Dental Appointments are scheduled in units of time. In a typical dental office, 1 unit will = 10 minutes. In a typical dental office, 1 unit will = 10 minutes.

Dental Scheduling These will be important to know for a dental office externship or job!!! These will be important to know for a dental office externship or job!!! Amalgam restoration ( AR) = 4 units = 40 min Amalgam restoration ( AR) = 4 units = 40 min Extractions = 5 units = 50 min Extractions = 5 units = 50 min Composite restorations = 6 units = 60 min Composite restorations = 6 units = 60 min

Dental Scheduling Suture Removal = 2 units = 20 min Suture Removal = 2 units = 20 min Crown Seat = 3 units = 30 min Crown Seat = 3 units = 30 min Root Canal Therapy ( RCT) = 6 units =60 min Root Canal Therapy ( RCT) = 6 units =60 min

Dental Scheduling Crown and Bridge ( C&B ) = 8 units Crown and Bridge ( C&B ) = 8 units = 80 min or 1 hr. 20 min = 80 min or 1 hr. 20 min Oral hygiene Instructions ( OHI ) = 2 units = 20 min Oral hygiene Instructions ( OHI ) = 2 units = 20 min Recall & cleaning ( RC ) = 6 units = 60 min Recall & cleaning ( RC ) = 6 units = 60 min

Dental Scheduling Cosmetic Restorations = 9 units Cosmetic Restorations = 9 units = 90 min or 1 hr. and 30 min = 90 min or 1 hr. and 30 min Recall = 2-3 units = minutes Recall = 2-3 units = minutes