Billing Extractions to Medical Plans
Understanding each medical carrier’s coverage guidelines is key to coding and billing extraction procedures to medical plans. Procedures covered by one medical plan may not be covered by another. For example, although some medical carriers cover the removal of impacted teeth, many do not. Some will cover extractions due to trauma or if the patient has specific medical conditions, while others will not.
Before a procedure is performed that could potentially be billed to a medical plan, contact the patient’s medical carrier by phone to ask the following: Is preauthorization required? Does the patient need a referral from his/her primary care physician? Are there provider limitations on the plan (i.e., network providers only or oral surgeons only)? Is a network gap exception available if there are no in-network providers within a reasonable distance qualified to perform the procedure? Having answers to these questions up front will ultimately save billing staff a tremendous amount of time.
Medical Coverage for Impacted Tooth Extraction
Full bony and partial bony impactions are the most commonly covered extractions, whereas coverage for soft tissue impactions is far less common. Even so, medical coverage for the in-office removal of impacted teeth is carrier-specific, and coverage for removal of third molars can be contract-specific for each employer group.
Be sure to check coverage for each patient, even if plans look similar. Two patients who work for the same company could have different coverage for the same procedure. However, obtaining accurate information can be challenging. Customer service representatives do not always fully read the policies when they are quoting benefits, so always give a disclaimer when relaying benefit information to patients and encourage them to verify benefits as well.
Simply asking if there is coverage for removal of impacted teeth will not provide the information you need. You must specifically ask, “Is there coverage for removal of impacted teeth in the office?”
Some medical plans provide coverage for the removal of impactions in the hospital but not in the office. However, even in these cases coverage is often only available if the patient has a condition that would make surgery in the office unsafe (i.e., a heart condition). Many of these plans cover the facility but not necessarily the removal of the teeth.
In addition to the general questions mentioned earlier, also ask the following: Is coverage limited to full bony impactions, or are partial bony impactions also covered? Is anesthesia considered part of the global procedure, or is it considered to be a separate procedure? Is there coverage for preoperative x-rays and evaluation?
Coding the Extraction of Impacted Teeth
If a medical CPT code accurately describes the services performed, then report the CPT code. However, if no specific CPT code accurately describes the service or the best choice is an unspecified code such as 41899 (unlisted procedure, dentoalveolar structure), then it is appropriate to report the correct HCPCS “D” code. The dental CDT codes are a part of HCPCS (Healthcare Common Procedure Coding System), and because they are a HIPAA standard code set, medical carriers should accept dental “D” codes on medical claims when no specific CPT code exists.
Since there is no specific CPT code for reporting the removal of impacted teeth, simply report the appropriate dental code in box 24D of the CMS-1500 medical claim form. If the carrier does not accept HCPCS codes, then report CPT 41899 and include a brief narrative describing the procedure performed.
Remember to also report the appropriate ICD-9 diagnosis code(s) in box 21 of the CMS-1500 claim form to support medical necessity for the procedures. Report the most specific ICD-9 code available and be certain to support the reported code with documentation in the patient’s chart.
The following codes may be billed to medical carriers for the extraction of impacted teeth (or a coronectomy):
D7220 Removal of impacted tooth – soft tissue (not usually covered)
D7230 Removal of impacted tooth – partial bony
D7240 Removal of impacted tooth – complete bony
D7241 Removal of impacted tooth – complete bony, complicated
D7251 Coronectomy - intentional partial tooth removal
41899 Unlisted procedure, dentoalveolar structures
520.6 Disturbances in tooth eruption
When reporting multiple extractions (of the same type) on the CMS-1500 medical claim form, most carriers prefer the procedure code to be reported once in box 24D and the number of extractions listed in box 24G (units box). For example, when reporting the removal of four bony impacted teeth, report code D7240 only once, and place a “4” in box 24G.
Medical Coverage for Erupted Tooth Extraction
Most medical carriers will only cover extractions of erupted teeth if they are linked to trauma or to medical necessity, such as removal of teeth prior to radiation therapy. However, just because a patient has a medical condition does not mean that extractions will automatically be covered. Furthermore, most medical plans do not cover routine surgical extractions since they consider it a dental procedure rather than a medical one.
When an extraction is related to trauma, you may need to provide details, such as time frame and the nature of the injury (i.e., was the injury due to an automobile accident?). The ICD-9 diagnosis code is key for plans that specify that extractions are only covered due to trauma or disease. Without reporting an ICD-9 code that communicates the medical necessity for the extractions, you will not be reimbursed for the services rendered.
If you think extractions of erupted teeth may be covered under a medical plan, call the medical carrier and be prepared to give both diagnosis codes and procedure codes.
Questions to Ask the Medical Carrier
Is there in-office coverage for extraction of an erupted tooth? Is there coverage if it is trauma-related? If so, are there specific time limits or details needed? Is there coverage for patients having extractions prior to undergoing radiation therapy? Transplant surgery? Are diagnostic x-rays and evaluations also covered? (Some carriers will cover the procedure but not the evaluation.) And lastly, is general anesthesia or IV conscious sedation included in the extraction, or is it considered a separate procedure?
Coordination of Benefits
Some coordination of benefits may be necessary when a patient has both medical and dental benefits. When coordinating benefits between medical and dental plans, most carriers consider medical insurance primary if the patient has coverage. This is why some dental carriers require surgical extraction claims to be submitted to medical before they will consider them for payment. However, there are no absolute rules, so be prepared to give the effective date of each plan when you contact the carrier.
What About Other Medical Conditions?
Radiation therapy and trauma are not the only reasons dental extractions may be covered under a medical plan. Some carriers cover the extraction of teeth if a patient has immunodeficiency due to AIDS or if they are taking immunosuppressant drugs because of organ transplant. Others may cover the surgery prior to chemotherapy or for osteoradionecrosis(death of bone due to radiation) of the head and neck. Again, this is carrier-specific, soit is important to call each medical plan to see what coverage is available.
Since there is no specific CPT code for the extraction of an erupted tooth, the dental “D” codes can be reported (i.e., D7140 simple extraction, erupted tooth or D7210 surgical extraction of an erupted tooth). If a medical carrier requires a CPT code (a few still do), report CPT code 41899—unlisted procedure, dentoalveolar structures—and include a brief narrative describing the procedure performed in box 19 (or in the shaded area above the procedure code).
What About Medicare?
What Medicare does, other carriers often eventually follow. Currently, Medicare will only cover extractions when performed in preparation for radiation treatment for neoplastic diseases (a new uncontrolled growth or tumor) involving the jaw. There is no coverage under Medicare for extractions when radiation therapy is used to target tumors in other areas of the body even if the radiation oncologist recommends them.
When reporting extractions prior to radiation therapy, contact the patient’s oncologist to obtain the correct ICD-9 code for your patient’s specific malignancy. There are many different ICD-9 codes for malignancies, and they are categorized by primary, secondary, and/or in situ sites on the body. By contacting the patient’s oncologist, you will be certain you are reporting the correct ICD-9 code.
Reporting ICD-9 codes in the proper order is also critical for reimbursement. In a situation involving a malignancy, the malignancy code is primary (listed on line 1 of box 21 of the CMS-1500 claim form). A secondary ICD-9 code—V07.8 other specific prophylactic measure—must be reported to inform the carrier of the preventive nature of the extraction. This is the key to getting this type of claim paid. Additionally, you should report the ICD-9 code that describes the reason the teeth need to be removed (i.e., perio disease, abscess, etc.) to inform the carrier that you are not removing healthy teeth.
Under certain circumstances, Medicare also reimburses for exams, though not treatment, before kidney transplant or heart valve replacement. And, since January 1, 2010, Medicare no longer accepts consult codes, so if you are conducting an exam based on a referral, use the new or established patient CPT codes (99201-99205 or 99211-99215 series).
It is appropriate to report extraction procedures to medical plans using our dental codes (CDT) because they are a subset of the HCPCS medical code set and are more specific than the unlisted CPT procedure code option (41899).Coverage for extractions under medical plans is carrier-specific and sometimes contract-specific. What one carrier covers under its medical policy may not be considered medically necessary/covered by another medical carrier or employer group.It is important to phone each patient’s medical carrier, relay the patient’s specific diagnosis and procedure codes, and ask the targeted questions on the Medical Phone Preauthorization template (inserted into this newsletter for your convenience) in order to understand each patient’s medical coverage guidelines and limitations.
Once you have determined the medical necessity of a procedure and reviewed and understand the carrier’s guidelines, you are well on your way to properly coding and successfully billing extractions to medical plans.