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American Association of Oral and Maxillofacial Surgeons

Coding FAQ

  1. Arch Bar Removal
  2. Waiting for Pathology Reports
  3. Sagittal Split CPT Code 21196
  4. Reporting Anesthesia by Surgeon to Medicare
  5. Coding Bone Grafts
  6. Exam under Anesthesia / Decision for Surgery
  7. Exploratory Procedures
  8. Coding and Billing for a Facility
  9. CDT Extraction Codes
  10. Coding a Rapid Palatal Expansion Procedure
  11. Coding Distraction Osteogenesis
  12. Coding Orthodontic Anchorage
  13. Coding Marsupialization of a Cyst
  14. Extractions Prior to Radiation Therapy
  15. Coding a Sleep Apnea Appliance
  16. Coding BRONJ
  17. Reporting Tooth Numbers
  18. PRP
  19. Coding Coronectomy/Partial Odontectomy
  20. General Anesthesia
  21. Billing for Resident Services
  22. Diagnosis Code for ADA Claim Form

The information provided to you is intended for educational purposes only. In no event shall AAOMS be liable for any decision made or action taken or not taken by you or anyone else in reliance on the information provided. For legal or other professional advice, you need to consult your own professional advisers.


Question:

Can you help me with coding for arch bar removal? We did a closed reduction of a right mandibular subcondylar fracture 60 days ago. Now the patient is ready for the arch bars to be removed. It is my understanding that since the arch bars are being removed during the 90 global period that we cannot charge for that procedure. Is that correct?

Answer:

The appropriate code for reporting arch bar removal is CPT 20670 — removal of implant; superficial. It is the position of the AAOMS Committee on Health Care and Advocacy that the removal of arch bars placed in the treatment of a fracture is a separately billable service and not included in the global package of the fracture repair surgery — regardless of who (same surgeon or different surgeon) placed the arch bars in the first place.

Some carriers may require a modifier be appended if the removal is performed within the global period of the initial surgery. Depending on the circumstances, modifier —58 may be an appropriate option.

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Question:

I have several doctors who have told me that they learned from AAOMS that they should not file the charges on a biopsy until they receive the pathology report so that the diagnosis is correctly assigned to the charges. This makes no sense to me! I end up with claims for services provided sitting in my insurance queue for weeks while we wait on a report from the outside laboratory. Shouldn't we file the claim with the diagnosis that the doctor assigned when the patient was seen for a consultation?

Answer:

What the doctors have said is correct. When coding anything, whether it is a biopsy or a more extensive surgical procedure in the hospital OR, you always want to report the final diagnosis on the claim. That would be the postoperative diagnosis (as opposed to preoperative diagnosis) listed on the operative report -- or in this case of the biopsy, the final diagnosis coming from the pathology lab. While this may hold up billing at times, it is consistent with coding rules and will keep you out of trouble.

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Question:

When we bill out for 21196 does the reimbursement we receive from the insurance carrier involve both sides? I mean, we don't bill out 21196, then 21196 again with a 50 modifier? Is it implied with the code that a bilateral procedure is being performed?

Answer:

You are correct. Code 21196 — reconstruction of mandibular rami, and/or body, sagittal split; with internal rigid fixation — is inherently a bilateral code. Therefore, modifier -50 would not be appropriate. In fact, if this procedure is performed unilaterally, it would be appropriate to report it with modifier -52 to reduce the service.

Per CPT Assistant March 1997 Volume 7 Issue 3:

Question:

Does code 21196, Reconstruction of mandibular RAMI and/or body, sagittal split, with internal rigid fixation, refer to a single side or bilateral procedure?

AMA Comment:

Prior to 1996, code 21196 was considered a unilateral procedure, as the descriptor stated ramus. However, in 1996 the descriptor was changed to RAMI, therefore indicating that code 21196 is inherently bilateral. No bilateral modifier is used.

Per CPT Assistant April 1996 Volume 6 Issue 4:

Question:

I noticed in my 1996 CPT book that the mandibular reconstruction codes (21193 - 21196) were changed this year, and now are to be used for a bilateral procedure. What code do I report for a unilateral procedure?

Answer:

CPT codes 21193 and 21195 (as well as 21194 and 21196) were revised in CPT 1996 to more clearly define that these procedures are typically performed on both sides of the mandible, (eg, an osteotomy on the RAMI [plural] as opposed to the ramus [singular]). The procedures reported using these codes (21193 - 21196) are inherently bilateral. For a unilateral procedure, the CPT modifier -52, reduced services, may be reported, in addition to the surgical reconstruction code, to indicate that the service performed was partially reduced at the physician's discretion. Additionally, you may wish to check with your third-party payors for more information concerning the reporting of unilateral procedures.

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Question:

How would I bill Medicare for general anesthesia or IV sedation performed by the oral surgeon? We have been running into trouble trying to bill it with -AA and/or other modifiers?

Answer:

Currently, Medicare does not allow separate reimbursement for general anesthesia when rendered by the operating surgeon, as they consider the reimbursement to be included in the reimbursement of the surgical procedure. Therefore, OMSs may not separately charge Medicare, nor Medicare beneficiaries for general anesthesia services. Since many third party payers utilize Medicare policy it is possible that other insurance carriers may also bundle payment for general anesthesia.

While AAOMS advocates third party payers provide separate coverage for anesthesia services, OMSs are also encouraged to work directly with their contracted third party payers.

On the other hand, many more Medicare carriers have reported separate payment for operator administered moderate sedation (99143-99145). You may wish to contact your local Medicare carrier to determine if separate payment for moderate sedation is allowed in your area.

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Question:

When is it appropriate to use codes 20900 and 20902 for bone grafts?

Answer:

The heading above codes 20900 and 20902 in the CPT book states "Codes for obtaining autogenous bone, cartilage, tendon, fascia lata grafts, or other tissues through separate skin/fascial incisions should be reported separately unless the code descriptor references the harvesting of the graft or implant (eg, includes obtaining graft)." It would be inappropriate to separately report codes 20900 or 20902 with many of the grafting codes most commonly used by oral and maxillofacial surgeons (such as 21210 and 21215) since they contain the phrase "includes obtaining graft". An example of the use of 20900 or 20902 might be with codes 20955-20962 for a bone graft with microvascular anastomosis. As codes 20955-20962 do not state "includes obtaining graft", it would in these instances be appropriate to separately report the bone harvest.

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Question:

In our office this morning we saw a 1 year old patient that had fallen out of a shopping cart a few days earlier. It was decided that he needed to go to the OR so he could be examined for a possible jaw fracture under anesthesia and at the same time have two teeth extracted. The doctor did a history and physical in the office before going to the OR. Please advise how to code the office part and exam in OR. The doctor did end up extracting the two teeth but there was no evidence of a jaw fracture.

Answer:

As a specific code for exam (of the jaw) under anesthesia does not exist in CPT, the use of an unlisted code such as 21499 may be appropriate.  The extractions would be separately billable using the dentoalveolar unlisted code, 41899.  Documentation should be submitted along with the claim.  As far as the office portion - if the visit meets all of the criteria of a specific level of new or established patient evaluation and management office visit (meaning history, exam and medical decision making) it would be appropriate to bill that level E&M code.  If the office visit took place the same day or the day before the patient was taken to the OR, and it was at that visit determined to be necessary to take the patient to the OR, it would be appropriate to append the -57 (decision for surgery) modifier to the E&M service code.  Additionally, remember to add to the diagnosis codes the appropriate ICD-9-CM E-code for the fall.

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Question:

We had a patient scheduled to come in for biopsy of a mandibular cyst, however when the patient came in for the surgery, the doctor did not find anything. We are having a difference of opinion on whether or not we keep the same code we originally would have used if there had been a cyst, use a different procedure code, or perhaps use a reduced fee modifier with the original code? Thank you for any help you can give us.

Answer:

Since there was no cyst found when the doctor went in to do the procedure, it cannot be coded as a cyst. You can consider using an abnormal radiological findings ICD-9 code like 793.0 (that is if something abnormal was seen on an x-ray) or code V71.89 (observation for suspected condition not found). As far as the procedure code, you can only code as far as the extent of the procedure actually carried out. So an unlisted code would be advisable over the mandibular biopsy code reduced with the -52 modifier. The March/April 2004 AAOMS Today Coding Corner (page 15) addressed a similar issue.

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Question:

My practice has recently become an accredited ambulatory surgery center. May I now submit a facility fee for all services rendered in the surgery center?

Answer:

You may not bill a facility fee for every procedure rendered in the ambulatory surgery center (ASC), only for those that the carrier deems "approved" for the ASC. CMS issues a list of "approved services" for the ASC setting every year in the Hospital Outpatient Prospective Payment System fee schedule. In general, commercial payers tend to follow CMS guidelines and policies, therefore may also utilize this list. CMS looks at historic billing, billing trends and site of service patterns from Medicare claims data in determining which procedures they feel may be safely performed in the office versus in the facility, such as an ASC or hospital. Many medical/surgical services provided by an OMS fall onto the covered list of ASC procedures, while a large number of dental services do not. The entire list of covered ASC procedure codes as well as their current payment rates can be found at http://www.cms.gov/ASCPayment. When submitting to a third party payer, you will first want to determine how or if they have developed a list of covered procedures and how they recommend submitting for the facility fee.

As most OMSs know, reimbursement for services rendered in the office include reimbursement for practice expenses, such as use of the operatory; clinical staff time; surgical equipment and supplies; and administrative record keeping and documentation. However, when rendering services in a facility setting, such as in the hospital or ASC, the facility is considered a separate entity from your office; therefore reimbursement for these expenses may be captured in a facility fee.

Keep in mind, CMS also maintains a list of "Inpatient Only" codes as well as a list of "Office Based Procedures". Therefore when rendering a service that falls on one of these lists in the ASC, it is likely that the facility fee will not be reimbursed. Depending on the terms of your contract or participation with the carrier, the patient may not be billed for fee when denied.

For additional information on billing for services rendered in the ASC, you may be interested in the AAOMS Coding Paper on Ambulatory Surgery Center Billing at /docs/practice_mgmt/coding_papers/asc_coding_and_billing.pdf or visit the CMS website at http://www.cms.gov/center/asc.asp.

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Question:

How much of the crown has to covered by bone to report CDT code D7230- "removal of impacted tooth-partially bony" and code D7240- "removal of impacted tooth- completely bony extractions"?

Answer:

In the descriptors of code D7230," part of the crown is covered by bone" and with D7240" most or all of crown is covered by bone". According to the ADA this determination is made based on the clinical evaluation of the treating dentist and his/her determination of what constitutes "most." Radiographic images may not provide complete or accurate information as to tooth position and surgical technique indicated for removal, therefore detailed documentation of the procedure and the surgeon's findings is strongly encouraged.

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Question:

What does RPE stand for and how is it coded?

Answer:

RPE stands for Rapid Palatal Expansion. This procedure is reported with CPT Le Fort I code 21142 and reduced with the -52 modifier to account for the lack of down-fracturing. The May/June 2005 AAOMS Today Coding Corner (page 13) addressed this issue.

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Question:

How does AAOMS recommend we report a distraction Osteogenesis procedure?

Answer:

A series of codes are necessary to report a distraction osteogenesis accurately. In essence, the procedure involves some type of osteotomy, but not one carried to completion; application of a distraction device; adjustment of the device; and eventual removal of the device. As an example, consider mandibular advancement using distraction osteogenesis.

CPT 21193-52 or 21195 - 52 (reconstruction of mandibular rami - reduced) would be used to report this initial procedure. Because the osteotomy was not carried out in its entirety, the -52 modifier is appended to indicate a reduced service. Even though the code is inherently bilateral, the appended -52 modifier would still need to be appended even if the procedure were performed unilaterally. For alveolar distraction codes 21198 or 21206-52 can be used

Application of the distraction appliance would be coded with CPT code 20690 (uniplane external fixation appliance) or 20692 (multiplane external fixation system). These codes are for unilateral application. As such, the -50 modifier would be applied is applied bilaterally.

Adjustment of the fixation system would be reported with CPT code 20693 (adjustment of revision of external fixation system requiring anesthesia). If not performed under general anesthesia, adjustment is considered part of the global surgical package for the application procedure (20690 or 20692).

Removal of the fixation system would be coded as CPT 20694 (removal under anesthesia of external fixation system). Again, if the removal is done without general anesthesia, it is considered part of the global surgical package for application of the system.

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Question:

Our office recently performed a procedure the surgeon described as Orthodontic Anchorage. Apparently this is the placement of implants for orthodontic anchorage when there is no dentition to support anchorage. How should this be reported to medical and/or dental insurers?

Answer:

CPT code 20650 — Insertion of wire or pin with application of skeletal traction, including removal (separate procedure) — accurately describes the work and practice expense involved with providing this service.

Possible codes for reporting this service to a dental carrier include D7292, D7293 or D7294 depending on the specifics of the case.

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Question:

How would you code the marsupialization of a large odontogenic cyst of the maxilla? The oral and maxillofacial surgeon plans to open the cyst and insert a tube in order to allow the cyst to decompress.

Answer:

There is no one distinct code for this situation in CPT, however there are three possible ways to approach reporting it. Marsupialization involves opening of the bone, an incisional biopsy of the lining, and finally, insertion of a tube for decompression. This assumes a rather prolonged course of follow up and frequent office visits (weeks to months) before the definitive surgical excision is performed. Thus, the first method to consider is reporting a biopsy of lesion code with a low RVU and 0 or 10 day global in addition to a low RVU incision and drainage code also with a 0 or 10 day global. Each follow up visit beyond the 0 or 10 day global period should be coded separately with the appropriate established patient E&M code. This method would reflect the longitudinal work in these cases that can extend over several months. If a shorter follow up is anticipated, other options may be considered. The second option would be to use unlisted CPT code 21299, which requires a report, and append staged procedure modifier -58. The staged procedure would indicate that a second procedure was planned from the outset (excision of benign cyst) in the event that it falls within the global surgical period of the first procedure. In the report, reference CPT 42409 (marsupialization of sublingual gland) as the equivalent procedure with an RVU of 6.35 and 90 day global period. The third option would be the use of an excision code with a 90 day global. If this code is selected as your preferred method of billing — you may not charge for any follow-up visits during the 90 day post-operative period.

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Question:

We performed extractions on a Medicare patient prior to planned radiation therapy for a malignancy. How should we report this? We are located in Texas and our Medicare carrier is Trailblazer.

Answer:

While this may vary by carrier, ICD-9-CM code V07.8 — other specified prophylactic measure — followed by the ICD-9-CM code representing the patient's head or neck cancer appropriately describes the indications for performing this service.

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Question:

Do you know if there is a specific code for a sleep apnea appliance? In this case we are taking the impressions in the office and sending them out to a lab. Once we receive the appliance I bill with E1399, but I am getting denials.

Answer:

There are actually a few different ways you can potentially report this.

If the appliance is being designed and fabricated by the doctor in the office and it is not being sent to an outside lab, consider using code 21089 (unlisted maxillofacial prosthetic procedure). Additionally, a letter of explanation would be required as this is an unlisted code. If on the other hand, an outside laboratory is fabricating the appliance, (which is the scenario per your e-mail), CPT supply code 99070 should be reported and the invoice from the lab should accompany the claim. A letter of explanation indicating what the code is being used for might also be a good idea.

Another option would be to report the HCPCS Durable Medical Equipment "E" codes. E0485 (oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, prefabricated, includes fitting and adjustment) or E0486 (oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment) could be appropriate.

The code you mention, E1399 is for miscellaneous durable medical equipment. It might be that one of the above is a bit more specific and preferred by the payer.

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Question:

My doctor is doing a procedure on a patient with bisphosphonate related osteonecrosis of the jaw (BRONJ). How should I code this diagnosis?

Answer:

There are two different ways at looking at coding for BRONJ. In a case where BRONJ is suspected but no clinical or radiographic signs are evident, you would use the ICD- 9-CM code, V71.89 (observation and evaluation for other specified suspected condition) accompanied by the appropriate Evaluation and Management (E& M) code for the clinical evaluation.

In the cases where a diagnosis of BRONJ is confirmed, there is an ICD-9- CM code for aseptic osteonecrosis of the jaw, 733.45. There are also two ICD-9-CM E codes, E933.6 and E933.7 to track the route of administration. E933.7 describes the use of bisphosphonates administered intravenously and E933.6 describes the oral administration of the drug. In addition to these codes, an E code can be used to list the appropriate drug or drugs given in combination with the bisphosphonates, such as antineoplastic and immunosuppressive drugs (E933.1). Use of the appropriate ICD-9-CM code for the disease state (e.g., particular cancers, osteoporosis or Paget's disease) may also be required.

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Question:

How do you report tooth numbering on the CMS 1500 form?

Answer:

Field 24 on the CMS 1500 form has been updated to accommodate the reporting of tooth numbers and area of the oral cavity. The revised instructions are available on the National Uniform Claim Committee (NUCC) website. There is now a shaded area in fields 24A-24G where you may report tooth numbers and other supplemental information such as anesthesia time and narrative descriptions of unspecified codes. A qualifier should be used when reporting any of these services.

To report a tooth number, report data in the following order: qualifier, tooth number, e.g., JP16. When reporting an area of the oral cavity, enter in the following order: qualifier, the area of oral cavity code, e.g., JO10.

  • When reporting multiple tooth numbers for one procedure, report in the following order: qualifier, tooth number, blank space, tooth number, blank space, tooth number, etc., e.g., JP1 16 17 32.

  • When reporting multiple tooth numbers for one procedure, the number of units reported in 24G is the number of teeth involved in the procedure.

  • When reporting multiple areas of the oral cavity for one procedure, add in the following order: qualifier, oral cavity code, blank space, oral cavity code, etc., e.g., JO10 20.

  • When reporting multiple areas of the oral cavity for one procedure, the number of units reported in 24G is the number of areas of the oral cavity involved in the procedure.

The following qualifiers may be used:

7 Anesthesia information
ZZ Narrative description of unspecified code
N4 National Drug Codes (NDC)
VP Vendor Product Number Health Industry Business Communications Council (HIBCC) Labeling Standard
OZ Product Number Health Care Uniform Code Council — Global Trade Item Number (GTIN)
CTR Contract rate
JP Universal/National Tooth Designation System
JO ANSI/ADA/ISO Specification No. 3950-1984 Dentistry Designation System for Tooth and Areas of the Oral Cavity

The following are the codes for tooth numbers, reported with the JP qualifier:

1—32 Permanent dentition
51—82 Permanent supernumerary dentition
A—T Primary dentition
AS—TS Primary supernumerary dentition

The following are the codes for areas of the oral cavity, reported with the JO qualifier:

00 Entire oral cavity
01 Maxillary arch
02 Mandibular arch
10 Upper right quadrant
20 Upper left quadrant
30 Lower left quadrant
40 Lower right quadrant

For further information on these codes, refer to the Current Dental Terminology (CDT) Manual available from the American Dental Association.

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Question:

How do you code the use of platelet rich plasma (PRP) in bone augmentation procedures?

Answer:

As of July 1, 2010 a new Category III CPT code is available for reporting the use of platelet rich plasma. A category III code is a temporary code describing an emerging technology, service and/or procedure that may or may not eventually be converted to a Category I CPT code. The descriptor for code 0232T reads "injection(s), platelet rich plasma, any tissue, including image guidance, harvesting and preparation when performed)". While the code will be published in the Category III code section of the 2011 CPT manual effective January 1, 2011, the new PRP code (0232T) can be used starting with dates of service July 1, 2010. Pages 4-5 of MLN Matters article MM6996 and an AMA CPT Category III Codes document provide additional information on the implementation schedule for Category III CPT codes.

Before July 1st code P9020 (platelet rich plasma, each unit) found in the HCPCS Book under the title "Pathology and Laboratory" and in the subtitle "Miscellaneous Pathology and Laboratory" was commonly reported. There are special coverage instructions associated with this code, which means local Medicare carriers may have specific coverage instructions for processing this code. The use of this or any other code does not guarantee payment. OMSs are encouraged to review their Medicare provider manual or carrier's website, or consult with the third party payer for coverage information.

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Question:

The surgeon I work for is performing a procedure that I'm unfamiliar with called coronectomy/partial odontectomy. How would I code this type of procedure?

Answer:

A coronectomy/partial odontectomy is the removal of the crown of an impacted tooth with intentionally leaving behind the roots. This code was previously reported using the appropriate extraction code, such as D7230 or D7240, depending on how much of the crown was covered by bone. Now this procedure can be reported with CDT code

D7251 - coronectomy - intentional partial tooth removal
Intentional partial tooth removal is performed when a neurovascular complication is likely if the entire impacted tooth is removed.

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Question:

A carrier is questioning my claim for general anesthesia noting that the time billed does not match my documentation. Will you please clarify the start and stop times when administering anesthesia?

Answer:

CDT has similar guidelines to CPT when it comes to the reporting the start and stop times of anesthesia. According to the CDT anesthesia descriptors, "Anesthesia time begins when the doctor administering the anesthetic agent initiates the appropriate anesthesia and non-invasive monitoring protocol and remains in continuous attendance of the patient. Anesthesia services are considered completed when the patient may be safely left under the observation of trained personnel and the doctor may safely leave the room to attend to other patients or duties."

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Question:

We practice at a teaching hospital. Our residents see patients in the ER for consultations but our billing office cannot charge because our attending does not physically see the patient that day but is consulted by telephone. My question is since we can't bill ER consults because our attendings are not present, would a subsequent office visit in the clinic be charged as a new pt exam?

Answer:

There are a few possible responses to this question. The scenarios below demonstrate how Medicare payments would be handled. Payments by third party payers most likely follow the same guidelines. However, to be sure, it is recommended that the payer be contacted prior to submitting a claim.

1. If the resident provides services at a hospital, in their role as a resident, the hospital receives funds (Part A) through its GME (Graduate Medical Education) and IME (Indirect Medical Education) payments. The funds do not get issued through the MPFS (Medicare Physician Fee Schedule - Part B). Therefore a CMS 1500 would not be submitted. The hospital bills the encounter with a CMS 1450.

2. If the resident provides services outside their educational responsibilities (like a separate part time job - even at the hospital where the residency is being done), the resident can bill for those services under MPFS. In these cases, the services are considered to have been furnished by the individual as a physician, not as a resident.

3. Considerations:

  1. Is covering the ER part of his/her educational training as an OMS?
    1. If yes, the resident cannot bill separately for the service provided under MPFS. It is part of the training experience.
    2. If no, the resident can bill separately under MPFS. However, in Scenario 1, the attending physician would not bill either, since he/she was not present.
  2. Is seeing patients in the clinic part of his/her educational training as an OMS?
    1. If yes, the resident cannot bill separately for the service provided under MPFS. It is part of the training experience. Furthermore, the attending physician can only bill if he/she was physically present during the clinic visit overseeing and teaching the resident.
    2. If no, the resident can bill separately under MPFS.

The biggest decision to always make is "was the resident working that day or during that encounter as part of his education requirements as an OMS resident?" If the answer is Yes, no separate billing is allow by the resident. If the resident is working outside of his educational requirements (like a part time job), those services are billable. Lastly, the teaching physician can only bill if he/she is physically present during the encounter/service.

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Question:

I noticed there is a box for a diagnosis code and POS code on the new ADA claim form. Do I have to report these on all claims?

Answer:

You are correct the ADA Dental Claim Form has been revised to incorporate key changes to the HIPAA standard electronic dental claim transaction. Some of the changes include the reporting of diagnosis codes and diagnosis code pointers, Place of service codes, and other medical and dental coverage.

The new ADA claim form will support reporting up to four diagnosis codes per dental procedure. According to the claim form instructions, “a diagnosis code will be required when the diagnosis may affect claim adjudication when specific dental procedures may minimize the risks associated with the connection between the patient’s oral and systemic health conditions.” The required Place of Service Codes will be the same Place of Service Codes required on medical claim forms.

The AAOMS encourages members and their staff to start to work with their vendors. The revised ADA Dental claim form and complete instructions may be found on the ADA website at http://www.ada.org/7119.aspx .

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