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Practice Management & Allied Staff News & Materials

Coding and Reimbursement Trends

December 12th, 2012

This article features a summary of coding and reimbursement trends based on inquires placed to AAOMS Headquarters staff in 2011 and 2012. All inquiries posed to AAOMS coding and reimbursement staff are tracked in order to identify coding and reimbursement trends as well as to advocate on the membership's behalf should the need arise.

By tracking member concerns, AAOMS can more effectively address issues with organizations such as the coding and reimbursement committees of the American Medical Association (AMA), American Dental Association (ADA), and National Committee on Vital Health Statistics (NCVHS). AAOMS may also use this information when dealing with specific insurance carriers, both independently and through the AAOMS/Insurance Industry Open Forums, as well as at events such as AAOMS' Day on the Hill and in interactions with other specific regulatory and governmental agencies.

Below is a summary of the most frequently raised coding and reimbursement issues brought forward in 2011 and 2012:

Coding

Grafts:
In relation to grafts the majority of calls were in regards to whether a membrane is included in dental code D7953 and CPT code 21210 and how to bill for BMP (bone morphogenic protein) and PRP (Platelet Rich Plasma). Additional questions raised related to grafting were whether a graft can be placed the same day as an extraction and implant placement. Many members also called seeking clarification on the new harvest code D7295 such as when is it appropriate to use. For more information on grafting the Coding Corner Colum in the May/June 2008 and Sept/Oct 2012 issues of the AAOMS Today addresses these concerns as well as the AAOMS Clinical Condition Statement on the Bone Grafting after the removal of third molars and a position paper Regarding Autogenous Bone Grafting CDT codes all of which are available on the AAOMS website.

Anesthesia:
The proper submission of anesthesia codes to medical carriers, such as the difference between CPT anesthesia chapter codes (eg 00170, 00190), the 47 modifier and moderate conscious sedation codes continues to be an area of confusion for AAOMS members and their staff. Additional concerns include the use of modifiers, such as the -47 modifier and the denial of codes from the Anesthesia chapter because some carriers are requesting the use of the modifier "AA". The Modifier "AA" (which is a HCPCS modifier) and will never be used by an OMS , reporting HCPCS J-codes for the drugs given, and clarification of anesthesia start and stop times. Staff referred callers to the Coding Corner Colum in the July/Aug 2012, Jan/Feb 2012 and the Jan/Feb 2011 issues of the AAOMS Today and the AAOMS Clinical Condition Statement on the Bundling of Anesthesia, and the Coding Paper on Anesthesia. Archived issues of the Coding Corner and Clinical Condition Statement series are available on the AAOMS website.

Trauma:
Reporting the placement and removal of arch bars and wires related to mandibular fractures as well as extracting broken teeth resulting from various types of trauma is at the top of the list of trauma calls received. Additional inquires included whether repair of multiple fractures of the mandible and can be billed separately or will it be considered unbundling. For more information regarding the billing of mandibular fractures take a look at the Coding Corner Column in the Sept/Oct 2010 issue of the AAOMS Today.

Radiology:
I-CAT scans such as cone beam and the new CMS Imaging Accreditation Requirements have generated a high volume of calls among AAOMS members. TMJ x- rays, re-reading of MRIs and cross coding from dental to medical cone beam codes have also been some of the most asked questions by members. For more information regarding the CMS' Advanced Imaging Accreditation requirement a please visit the Practice page of the AAOMS website at http://www.aaoms.org. Additional information on the coding of cone beam scans can be found in the Coding Corner Colum in the March/April 2009 and May/June 2012 issues of the AAOMS Today.

Evaluation and Management:
A majority of the calls placed regarding Evaluation and Management services pertained to CMS' elimination of consultation codes and the proper way to report such services to Medicare. Members also questioned the differences between Consults and Evaluations and whether an E&M code may be reported if on the same day as a procedure. Other questions regarding E&M codes was how to report Evaluation and management codes if the OMS was not the admitting doctor and if an E&M code can be used in that situation. More information regarding the coding of Evaluation and Management services can be found in the Coding Corner Colum of the Sept/Oct 2011 AAOMS Today.

Reimbursement

Third Molars:
Many members have contacted the AAOMS staff concerning third party payers denying the extraction of asymptomatic third molars. Most specifically Aetna, Anthem BCBS, Delta and Metlife have been denying third molar claims when the procedure is not "necessary" or when there no presence or potential for pathology associated with the third molar teeth. The AAOMS has a number of documents resulting from the Third Molar Study conducted several years ago as well as sample appeal language to assist members in their appeal efforts which can found on www.aaoms.org. The AAOMS has also developed the "White Paper on Third Molar Data" which discusses the considerations involved in deciding why, when or how to treat third molar teeth. The White Paper is available on the Members Only section of the AAOMS website at aaoms.org.

Opting Out:
The AAOMS is aware the Medicare Opting-out provision that was released in the Medicare Modernization Act of 2003 is still an area of confusion for many members. Some members do not realize they must formally "opt-out" by submitting an affidavit to their local Medicare carrier notifying of the intent to opt out before entering into private contracts with their patients. The AAOMS provides a thorough explanation of opting-out as well as sample copies of the affidavit and private contract on its website. Also provided on the AAOMS website is a detailed comparison of the various participation options currently available to OMS' wishing to treat Medicare patients. This subject is also focused in the AAOMS Beyond the Basics Coding Workshop.

Degree of Provider:
Services such as anesthesia by surgeon, evaluation and management services, cone beam scans, and biopsies, have been denied by carriers such as BCBS, Aetna, Medicare, etc. based on the degree of the provider. Resources including sample appeal letters and documentation supporting the OMS scope of practice and training, are available to AAOMS members and their staff free of charge.

Dental coding vs. Medical:
It is often brought to the attention of the AAOMS staff that many AAOMS members are not aware that under the HIPAA Electronic Transactions and Code Set Standards, dental codes are reportable on a medical claim form since CDT and HCPCS are recognized code sets. When such denials occur, members may wish to file a complaint via the HIPAA Non-Privacy Complaint form which can be found on the CMS website at http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/Enforcement/HowtoFileaComplaint.html.

CBCT Accreditation:
With the implementation of Medicare's Advanced Imaging Accreditation requirement that went into effect January 1, 2012, AAOMS has fielded many inquiries from members as to how to become accredited and whether accreditation is necessary. The AAOMS recently became a sponsoring organization of the Computed Tomography (CT) division of the Intersocietal Accreditation Commission (IAC) to help develop the IAC standards and the corresponding application and application criteria for the dental practice which can be found on their website at http://intersocietal.org/ct/. The AAOMS has recently become aware that Aetna, Anthem, and Humana have implemented similar accreditation requirements for rendering advanced imaging services.

Anesthesia by Surgeon:
Adopting Medicare's policy, many carriers bundle the payment for anesthesia services administered by surgeon into the payment of the surgical procedure. The AAOMS frequently receives calls requesting information on how to obtain reimbursement for the anesthesia service provided during the procedure. Some of the most common carriers bundling this service are Medicare, Blue Cross Blue Shield, Aetna, Anthem, United HealthCare, etc. The AAOMS responds to such inquiries using the Clinical Condition Statement on Bundling Anesthesia as well as additional resources that can be found at www.aaoms.org.

Refund Requests by Carriers:
With the implementation of the Patient Protection and Affordable Care Act (PPACA) signed into law March 23, 2010 practitioners became responsible for returning any overpayments wrongfully given to them by a carrier. While this mainly refers to Medicare and Medicaid providers, other third party payers are beginning to adopt the same rule. Furthermore, many third party payers also conduct retrospective audits resulting in refund requests. To obtain the proper procedures to follow in accordance with the Patient Protection and Affordable Care Act as well as how to respond to third party payer audits visit the Practice Management section of the AAOMS website at http://www.aaoms.org.

PECOS (Medicare Provider Enrollment):
There have been many changes pertaining to Medicare enrollment the last few years, mainly with the with the Medicare Provider Enrollment, Chain and Ownership System (PECOS) enrollment system. With implementation of section 6405 of the Affordable Care Act, CMS now requires all Medicare providers who order or refer services for Medicare beneficiaries, including OMSs and general dentists, to enroll in Medicare and be registered in PECOS. Additional information on the PECOS system may be found on the Practice Management section of the AAOMS website as well as the CMS website at www.cms.gov.

AAOMS resources available to help members and staff with their coding and reimbursement concerns include:

  • AAOMS Coding & Billing Courses
  • AAOMS Coding Papers
  • AAOMS TODAY: Coding Corner and Health Policy Perspectives
  • AAOMS Web Site-Practice Management Section, including Coding & Reimbursement FAQs
  • AAOMS Services Inc. (ASI) OMS Staff Communique Publication
  • AAOMS Advocacy E-Newsletter
  • Access to AAOMS Coding and Reimbursement Staff

Visit www.aaoms.org for more information on these educational resources.