Coding For "Dental" Procedures - Please Help ...

WeisMed2015

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I'm an AAPC member, but I haven't started working on CPC because my workload is huge right now -and- there is no program for coding medically necessary "dental" procedures. So, I've been learning as I go. My issue is that the patients are counting on me and I'm hoping you guys can help me with a very specific coding case-type. The CPT codes I bill for this case-type are 21210/21215 bone graft + 21248/21249 dental implants + 21089 interim prosthesis and later 21089 final prosthesis.

Patient with diagnosed periodontal disease and history of trauma to the teeth presents with chief complaint, "I am tired of dealing with the pain. I am unable to chew my food. I have to tear my food with my hands; shredding it so that I can try to eat it. I still will choke on the food, though, because I can't chew it completely. Patient states she wore orthodontic braces while she was in her 20s. "I had to wear them for 8 years because I had it done at the dental school". Patient reports having sucked her thumb from childhood into her 20s.

Medical History Significant For: GERD; Barrett's Esophagus; Artificial Hip, 2004; Total Reconstructive Surgery On Both Feet, 2010; On-Going Ankle Pain; Difficulty Sleeping/Insomnia; Excessive Worry; Unpleasant Breath Odor; History Of Smoking.

Medications: Nexium, 40mg; Sumatriptan, As Needed;

Patient reports a stress level of MODERATE.

Dental History Significant For: History Of Tooth Loss As A Result Of Having Fallen, Cracking Her Teeth; History Of Orthodontic Therapy To Include Orthodontic Braces For A Period Of 8 Years, Performed At Dental School; Diagnosed Periodontal Disease.

Patient presents at examination with 3 maxillary teeth and 11 mandibular teeth remaining. Patient's existing fixed reconstructive prosthesis was placed when patient was in her 20s and is currently ill-fitting/defective. Patient's attestation of masticatory dysfunction with dysphagia are clinically and radiographically supported.

Diagnoses: Skeletal malocclusion. Severe deterioration of the maxillary and mandibular alveolar bone. Soft tissue damage resulting from repetitive motion trauma and irritation caused by the defective/ill-fitting prosthesis. Masticatory dysfunction. Improper diet and nutrition due to compromised masticatory function. 8mm Overjet. Deep overbite with impingement of palatal soft tissues. Supraeruption of a dentoalveolar segment resulting from lack of occlusion. Dentition is not intact: Edentulous at #1, #2, #3, #4, #5, #7, #10, #11, #12, #13, #14, #15, #16, Maxillary and #17, #18, #32, Mandibular. Severe periodontal disease. Erosion at tooth #19, #20, #21,#22, #23, #24, #25, #26, #27, #28,#29, #30, #31, Mandibular, due to GERD. Failure of previous treatment - fixed reconstructive prosthesis has failed. History of smoking, but no longer a smoker.

*** So, as you can see, this reconstructive procedure is certainly not cosmetic. The goal of the treatment is to improve the patient's physiological function. To get the services covered for the patient, I need to code the claim so that it is obvious that the treatment is to correct a physical/functional or physiological impairment to patient's performance of basic life functions.

Insurance plans have indicated that reconstructive procedures are considered medically necessary when both SKELETAL DEFORMITY and FUNCTIONAL IMPAIRMENT criteria are met.

Facial Skeletal Deformity - Anteroposterior Discrepancies; Vertical Discrepancies; Transverse Discrepancies; Asymmetries;..

That's EVERYTHING I KNOW ;-) .... Can you help me figure out code priority so I can win this claim battle for this patient and so many others? And, by the way, I need the codes in ICD9....

And... what codes are meant to be used 1st on the medical claim? Late Effect Codes or Disorder of Bone, for instance... which should I place 1st knowing that the 1st code "drives the claim" and I don't want my claim automatically kicked out as DENTAL...

Thanks to any and all who offer advice on this!!!
 

CodingKing

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It doesn't really matter if its considered cosmetic or not. Its pretty much a given that you need teeth to chew, Missing any part of the anatomy can cause a functional impairment. Its usually medical necessary to have this done. Yes, it would be nice if medical covered it but no matter how you manipulate the diagnosis it doesn't change anything related to coverage. You will need to look at the payers plan exclusions, they are specifically written to be very limited when it comes to oral structures

Usually coverage will be limited to Extraction of impacted wisdom teeth, Accidental injury to sound and natural teeth, emergency stabilization until patient can get to a dental professional, extractions to prepare for radiation & chemotherapy treatment, non tooth related cysts, congenital anomalies (not acquired).

I did see that some insurances will cover limited implants to support a denture under certain circumstances. No coverage for fixed prosthesis and the number of teeth affected or may need to be replaced in the future ( Excellus Blue cross - https://www.excellusbcbs.com/wps/wc...&CACHEID=5737b70d-4df0-47aa-9750-ed0c0c92d129)

I would make sure to get pre approval of the treatment plan is there first. This isn't going to be something you can just submit through claims without extensive documentation.
 

WeisMed2015

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Thank you for reading thru the notes and your thoughts on the process. I'm on a mission to get this covered for patients. Don't know how I'm going to do it, but I'm not going to stop trying. I've got my dentists being very involved in the patient intake process AND the documentation process. So, clinical findings/support of the treatment plan is something my doctors are able to provide. I just need more KNOWLEDGE about the coding process, I think. How do claims process? Is it true that the 1st code on the claim is the only code that really matters??? If I have an 8 or 9 series (ICD 9) code and I have the e code to accompany that 8 or 9 code, do I have to point to both the 8/9 code AND the e code for every procedure on the claim that pointing to the 8/9 code is relevant... in other words, are the codes a "pointer set" every time they are pointed to??? ...

I respect your posts, very much... knowing what you do - and - knowing that I'm seeking knowledge in the most expedient, relevant form possible... what would you recommend I pursue for CPC... I was looking at plastic/reconstructive last night... I think that might give me insight that I don't have currently AND help me help those dental patients....any guidance you can offer would be so appreciated!! sue
 

WeisMed2015

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An Exercise In Coding This Patient's Claim - Please Guide Me?

So: Insurance plans have indicated that reconstructive procedures are considered medically necessary when both SKELETAL DEFORMITY and FUNCTIONAL IMPAIRMENT criteria are met. My question is - based on the knowledge you guys have gained over time and claims submissions - What ORDER Should I Put The Following Diagnoses In If The Carrier Wants Me To Prove Both Skeletal Deformity And Functional Impairment?
Here's how I would code the claim... what do I have right? wrong?
What would make my argument stronger if the carrier wants skeletal deformity and functional impairment?

Can you help make me a competent coder for these patients who can't chew their food???

21210/21215 - Disorder Of Bone; Severe Maxillary Alveolar Atrophy; Severe Mandibular Alveolar Atrophy, Acquired Absence Of Teeth Due To Trauma?
21248/21249 - Disorder Of Bone; Failure Of Previous Treatment/Failure Of Maxillary Prosthesis; Skeletal Malocclusion; Masticatory Dysfunction?
21089 - Skeletal Malocclusion; 8mm Overjet; Deep Overbite With Impingement Of Palatal Soft Tissue; Supraeruption;

Also, what diagnoses codes would apply to the following types of " Facial Skeletal Deformity"
Anteroposterior Discrepancies
Vertical Discrepancies
Transverse Discrepancies
Asymmetries;..

Diagnoses I pulled from the writing... did I miss anything? how should I prioritize the coding??
Skeletal malocclusion.
Soft tissue damage resulting from repetitive motion trauma and irritation caused by the defective/ill-fitting prosthesis.
Ill-fitting/defective prosthesis.
Masticatory dysfunction.
Improper diet and nutrition due to compromised masticatory function.
8mm Overjet. Deep overbite with impingement of palatal soft tissues.
Supraeruption of a dentoalveolar segment resulting from lack of occlusion.
Acquired Absence Of Teeth Due To Trauma. Dentition is not intact: Edentulous at #1, #2, #3, #4, #5, #7, #10, #11, #12, #13, #14, #15, #16, Maxillary and #17, #18, #32, Mandibular.
Severe periodontal disease.
Adverse Effect Of Biological Substance. Erosion at tooth #19, #20, #21,#22, #23, #24, #25, #26, #27, #28,#29, #30, #31, Mandibular, due to GERD.
Failure of previous treatment - fixed reconstructive prosthesis has failed.
History of smoking, but no longer a smoker.
 

WeisMed2015

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Need Info On Purchasing Med Ins Coverage-If Plan Has Exclusion, How Do I Add Coverage

I've heard that employers have contacted their insurance plan representative and requested a kind of "rider/coverage" for the employees because one of the employees needed the additional services covered... How do you do this? I could help my dental patients get the coverage they need if I knew how to addendum their coverage to include the "corporately not covered" procedures that I'm coding for the "dental" treatments... Help??
 
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