Practice Management & Allied Staff
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Coding and Reimbursement Trends

May 2nd, 2007

This article features a summary of the coding and reimbursement trends of particular interest to OMS practices and is based on inquires placed to AAOMS Headquarters staff. All inquiries posed to AAOMS coding and reimbursement staff are tracked and trended to assist AAOMS in advocating on the membership's behalf.

By reporting concerns and frustrations, AAOMS can more effectively address common 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 can 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.

In response to AAOMS Today readers' requests, read on for a summary of the common coding and reimbursement issues brought forward in 2005 and 2006:

Coding

Anesthesia: Questions related to the 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 are common as are inquiries related to dental reporting mechanisms for general, deep, conscious sedation and analgesia. Related concerns include the use of modifiers, HCPCS J codes for the drugs given, anesthesia start and stop times and more.
Dentoalveolar Surgery: Questions related to specific codes for reporting dentoalveolar procedures and services to both medical and dental carriers, such as extractions, alveoloplasties, incision and drainage procedures and cyst removals come up often as this makes up a large part of the practice of many OMSs.
Trauma: Reporting fracture treatments, laceration repairs and the like often generate questions related to CPT code definitions of open versus closed, internal fixation, interdental fixation and multiple approaches. In addition, many inquire about arch bar removal, the appropriate use of modifiers and add on codes, and more.
Evaluation and Management: Staff is often asked about associated CPT guidelines and Centers for Medicare and Medicaid Services (CMS) Documentation Guidelines as well as modifier usage and the CPT definition of global surgical package.
Modifiers: Modifiers most often asked about include the �25 (significant, separately identifiable evaluation and management service by same physician on the same day of the procedure or other service), �47 (anesthesia by surgeon), -52 (reduced services), -57 (decision for surgery) �58 (staged or related procedure or service by the same physician during the postoperative period), -62 (two surgeons), -78 (return to the operating room for a related procedure during the postoperative period), �79 (unrelated procedure or service by the same physician during the postoperative period) and �80 (assistant surgeon).
Grafts: Questions about codes for mandibular and/or maxillary onlay bone grafting, sinus lifts, ridge preservation, socket grafting at the time of extraction, etc. are common inquiries received by AAOMS coding staff. Issues such as whether autograft harvesting, allografts, platelet rich plasma (PRP), supplies and materials such as bio-oss, pur-oss and membranes are separately reportable are among the intricacies addressed as well as related modifier usage on the medical side.
Implants: A common question asked is the difference between CPT codes 21248 and 21249 with regard to the definitions of partial and complete. On the dental side questions are often raised related to what is inclusive in the implant placement code versus what is separately reportable.

AAOMS resources available to help members and staff with these coding issues and others include:

AAOMS Coding Courses
AAOMS Coding Papers
AAOMS TODAY Coding Corner articles
AAOMS Web Site Coding FAQs
AAOMS Services Inc. (ASI) Approved Partner Program CodeCorrect
AAOMS Services Inc. (ASI) OMS Staff Communique Publication
Access to AAOMS Coding and Reimbursement Staff

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

Reimbursement

Billing: Many members have inquired about HIPAA's latest requirement that all providers obtain a National Provider Identifier (NPI). Other inquiries in this category relate to what is separately billable during the global period, billing for an ASC facility fee and other general claim filing questions.
Medical Necessity: Denials based on a failure to meet carrier medical necessity criteria are seen mostly as related to orthognathic surgery with the biggest challenges coming from United Health Care and Blue Cross Blue Shield according to reports received. Members reporting medical necessity denials for third molar removal most often cited Blue Cross Blue Shield and Aetna. Some medical carriers have begun questioning the medical necessity of providing general anesthesia and denying it when specific criteria is not met.
Opting Out: Something many members have inquired about over the last few years is the provision in the Medicare Modernization Act of 2003 giving doctors of dentistry the ability to opt out of Medicare. Questions arise related to the process, the differences between participating, non-participating and opted out provider status, as well as the pros and cons of each.
Anesthesia by Surgeon: The most common frustration related to anesthesia by surgeon is carriers who bundle it into the surgical procedure, often following the benchmark set by Medicare. In addition to questions about providing anesthesia to Medicare patients, among the medical carriers most often reported as bundling anesthesia are Blue Cross Blue Shield, Aetna, United Health Care and Wellmark.
Coordination of Benefits: The already complicated rules of coordinating benefits are compounded by the uniqueness of the specialty and the fact that coverage can exist under both medical and dental plans. As such, many inquiries received are related to overpayments, write off amounts and the order of benefits determination.
Fees: Inquiries received pertain to fee analyzers and where they can be obtained, the amounts billable to Medicare for participating providers versus the limiting charge for non-participating providers.
Degree of Provider: Denials of anesthesia services, trauma, lesion removals and sleep apnea procedures based on the degree of the provider are among those reported to AAOMS staff. Medicare, Medicaid and Blue Cross Blue Shield were cited most often as the payers issuing such denials. AAOMS appeal packets, including sample appeal letters and documentation of the OMS scope of practice and training, are available to AAOMS members free of charge.

Among the resources available to assist AAOMS members and staff with various reimbursement issues are:

New AAOMS Billing Course
AAOMS Appeal Packets (available upon request)
AAOMS Clinical Condition Statements/Orthognathic Surgery Criteria/Impairment Guidelines
AAOMS Insurance Manual: A Guide to Understanding, Filing and Appealing Claims
AAOMS Monthly Advocacy e-Newsletter
AAOMS Web Site Reimbursement FAQs
Access to AAOMS Coding and Reimbursement Staff