About Medical Insurance


 

About Medical Insurance

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While many NMD practices do not have much to do with insurance (except to assist patients in filing their own claims), if you treat pain/dysfunction patients, what insurance coverage there may be will probably be in a patient's medical coverage - not in their dental plan. If you have not treated TMD patients before, the differences in medical insurance may be new to you. While diagnostic codes (ICD codes) are reasonably specific, because the coding of medical insurance is essentially controlled by medical doctors, it is sometimes challenging to find a proper code for a procedure (CPT code) done by a dentist. You must choose the accurate code for the service you have provided.  [RN1] 
Virtually all states have laws prohibiting discrimination of coverage by professional degree. If what you are doing is lawful under your license, medical insurers should not deny coverage simply because you are a dentist.

Some of the basic coding information commonly used by NM practices is presented here. Should you desire more detailed information or professional assistance, it is available from Nierman Practice Management
www.NiermanPM.com or (800) 879-6468.

 

ICD Codes: These are diagnostic codes. Every medical claim requires at least one diagnosis code to support the medical necessity of the services rendered. Following are some of those commonly used in pain/dysfunction dental practices. The diagnosis coding system transitioned from ICD-9 to ICD-10 on October 1st, 2015. For services rendered prior to October 1, 2015, use the ICD-9 codes. For services rendered on or after October 1st, 2015, use the ICD-10 codes.

 

ICD-10 Codes (use for services rendered on or after October 1, 2015)

 

M26.61 - Adhesions and ankylosis of temporomandibular joint

M26.62 - Arthralgia of temporomandibular joint

M26.63 - Articular disc disorder of temporomandibular joint

M26.69 - Other specified disorders of temporomandibular joint

G50.0 - Trigeminal neuralgia

G50.1 - Atypical facial pain

G50.8 - Other disorders of trigeminal nerve

H92.01 - Otalgia, right ear

H92.02 - Otalgia, left ear

H92.03 - Otalgia, bilateral

H92.09 - Otalgia, unspecified ear

M26.52 - Limited mandibular range of motion

M54.2 - Cervicalgia

M79.1 – Myalgia

M79.2 - Neuralgia and neuritis, unspecified

R13.11 - Dysphagia, oral phase

R42 - Dizziness and giddiness

R51 – Headache

R68.84 - Jaw pain

S09.93XA - Unspecified injury of face, initial encounter

S19.9XXA - Unspecified injury of neck, initial encounter

 

ICD-9 Codes (use for services rendered prior to October 1, 2015)

360.2     Atypical Facial Pain

388.72   Referred Otalgia Pain

524.60   Temporomandibular joint dysfunction syndrome

524.63   TMJ Articular Disc Disorder

524.62   Arthralgia of the temporomandibular joint

624.69   Osteoarthritis (chronic) degenerative TMJ

721.1     Myalgia

723.1     Cervicalgia

729.2     Neuralgia, Neuritis, radiculitis, unspecified

780.4     Dizziness, vertigo

784.0     Cephalgia - Head /Face Pain

959.09   Injury to head/neck

 

CPT & HCPCS Codes: CPT codes are known as Level I codes. CPT codes are the procedural codes, used primarily to identify medical procedures and services provided by physicians and other health care professionals. HCPCS Codes are known as level II codes which primarily identify products, supplies, and services not included in the CPT codes . Following is a list of CPT & HCPCS codes used by many NMD practices.

 

20550 - Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia")

20551 - Injection(s); single tendon origin/insertion

20552 - Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)

20553 - Injection(s); single or multiple trigger point(s), 3 or more muscle(s)

21480 - Closed treatment of temporomandibular dislocation; initial or subsequent

21485 - Closed treatment of temporomandibular dislocation; complicated (eg, recurrent requiring intermaxillary fixation or splinting), initial or subsequent

70320 - Radiologic examination, teeth; complete, full mouth

70330 - Radiologic examination, temporomandibular joint, open and closed mouth; bilateral

70350 - Cephalogram, orthodontic

70355 - Orthopantogram (eg, panoramic x-ray)

70486 - Computed tomography, maxillofacial area; without contrast material

S3900 - Surface electromyography (emg)

64550 - Application of surface (transcutaneous) neurostimulator

97014 - Application of a modality to 1 or more areas; electrical stimulation (unattended)

97762 - Checkout for orthotic/prosthetic use, established patient, each 15 minutes

99070 - Supplies and materials (except spectacles), provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided)

 

Evaluation & Management Codes (i.e. office visit codes)

New patients:

99201 - Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.

99202 - Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 20 minutes are spent face-to-face with the patient and/or family

99203 - Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family.

99204 - Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family

99205 - Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family.

 

Established Patients:

99211 - Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.

99212 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.

99213 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family.

99214 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.

99215 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family

 

Consultation Codes: **These codes may be used when one health professional refers to another for their opinion or assistance in a treatment or part of treatment they cannot perform. It is required that a follow up letter be sent to the referring provider when these codes are used. Some insurers (Medicare, for example) no longer accept these codes, and a new or established E&M code should be used instead.

99241 - Office consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Typically, 15 minutes are spent face-to-face with the patient and/or family

99242 - Office consultation for a new or established patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low severity. Typically, 30 minutes are spent face-to-face with the patient and/or family.

99243 - Office consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Typically, 40 minutes are spent face-to-face with the patient and/or family.

99244 - Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family.

99245 - Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 80 minutes are spent face-to-face with the patient and/or family

 

 

HCPCS Codes: **The code commonly used to represent oral appliances to treat TMD, HCPCS code S8262 (which stood for: Mandibular Orthopedic Repositioning Device, Each), was deleted/retired from the medical coding system as of June 30th, 2015. There is not another code available currently that directly describes an appliance used to treat TMD. Different insurers seem to be accepting or preferring different codes currently. Some options to represent an appliance being used to treat TMD are:

D7880 - occlusal orthotic device, by report

D7899 - unspecified TMD therapy, by report

E1399 - Durable medical equipment, miscellaneous

A narrative reporting describing the appliance is recommended because they’re “by report” or “miscellaneous” codes.

It is a good idea to check out the TMD medical policy for the specific insurer being filed to see if there is a preferred code listed in the policy.

E0720 - Transcutaneous electrical nerve stimulation (tens) device, two lead, localized stimulation

E0730 - Transcutaneous electrical nerve stimulation (tens) device, four or more leads, for multiple nerve stimulation

* For the above two codes, add modifier-RR to the code for rentals, NU for New equipment for purchases

A4595 - Electrical stimulator supplies, 2 lead, per month, (e.g. tens, nmes)


 [RN1]This does not apply anymore.  CPT states the code must correspond with the description.  You can’t change the description and the descriptions don’t print on the claim form.

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