Pediatric Coding Alert

Question: Our state’s Medicaid program is requiring pediatricians to perform a dental exam at routine physicals and to report it with dental procedure code (D0145). We would like to use the same code when billing all of our insurance companies, but at least one payer has been rejecting claims that include this code, since they consider it an invalid code. Is there any simple way around this that will not require us to apply different rules to different payers, while at the same time meet Medicaid’s requirements?

North Carolina Subscriber

Answer: There are a few issues at play here that you must consider before reporting the service. First, you’re billing it to Medicaid because Medicaid is requiring the dental exam, but when billing a private insurer, you will need medical necessity as a reason for performing a dental exam, and most private payers will not reimburse this as a separate examination for a pediatrician. If they do, they may ask you to include the service in your E/M code, but whether that’s possible will depend on exactly what the pediatrician is doing.

If the doctor is simply giving a cursory look at the patient’s teeth and gums, along with advice on proper dental hygiene, that can count toward the “ears, nose, mouth, throat” organ system under the E/M guidelines and be included in your standard E/M code for non-Medicaid providers who don’t require that you perform the exam.