Medical Filing Tips For Dental Accident Claims

When submitting a claim for a dental injury to a medical plan, it is important to remember that not all injuries to teeth are classified as trauma. Some medical carriers define dental trauma as a “non-biting injury to a sound natural tooth.” For this reason, if someone fractures a tooth while biting into a popcorn kernel, the restorative services are not likely to be covered under a medical policy. Moreover, the health of the tooth prior to trauma can also play a role in determining coverage. Medical carriers typically only pay to restore sound natural teeth. A sound natural tooth is often defined as a tooth that is stable, functional, free from decay and advanced periodontal disease, and in good repair at the time of the accident. According to some medical plans’ accident policies, “Teeth must be free from decay, in good repair and firmly attached to the jawbone at the time of injury.” Some define a sound tooth as a “virgin or unrestored tooth.” Others consider a tooth sound only if the injured tooth had no decay, no filling on more than two surfaces, no gum disease associated with bone loss, no root canal therapy, is not a dental implant, and functions normally in chewing and speech. As you can see, the definition of a sound natural tooth can vary from carrier to carrier, which is also true of trauma related medical benefits. Check Coverage Limitations

Coverage for dental trauma is entirely plan dependent, which is why it is essential to contact each patient’s medical carrier to determine his/her medical plan guidelines. Some medical plans, for example, will only provide dental trauma coverage for the first 24 hours after an accident. Others require that the patient be seen within 72 hours of the accident. Others only require notification, not necessarily treatment, within 72 hours of the accident unless there are extenuating circumstances (e.g., the patient is in the hospital for the three days following the accident). It is wise to have the insured member also contact his/her medical insurance as there are carriers that require notification by the enrollee in order to prevent reduced or denied benefits. Carriers also often have specific time frames in which trauma related dental services must be completed. One carrier may require treatment to be finished within twelve months, and another may require estoration or replacement within the calendar year of the accident or during the next calendar year. The importance of contacting each medical carrier to clarify the patient’s coverage guidelines cannot be emphasized enough.

Request Authorization

Medical insurance representatives will need certain pieces of information when you call them to inquire about coverage, such as the patient’s name and date of birth, the subscriber’s name and date of birth, the medical ID number, accident details (e.g., what type of accident, when it occurred, etc.), a diagnosis code (ICD-9), and codes for the procedures you plan on performing. The complete treatment plan should be included when requesting prior authorization for services because it is sometimes difficult to go back to the carrier and request authorization for additional treatment.

Dental providers seeing a patient referred from another provider should not assume that a prior insurance authorization automatically extends to the services being provided in their office. Each provider’s office should contact the medical carrier to obtain authorization for the services performed in that office. For instance, if a patient is referred from a general dentist to an endodontist for a root canal, the endodontist may not have automatic authorization and should contact the patient’s medical carrier for a separate authorization of services. Some medical policies also require a primary care physician’s referral for trauma, so also ask the patient’s medical carrier if any referrals are needed. When you speak to the medical plan’s representative, you should not only ask about the specifics regarding coverage (e.g., what services are considered for coverage) but also if there is a deductible and/or dollar limit for dental trauma on the medical policy. Some medical policies set dollar limits on the amount of dental trauma benefits available per year or per tooth.

Typically, the first step with any dental trauma patient is the evaluation (office visit or consultation) and x-rays. When billing these services to medical insurance carriers, the appropriate evaluation and management (E & M) code is usually selected from the following coding series, which can be found in any current CPT (Current Procedural Terminology) book.

CPT 99201-99205 for a new patient

CPT 99211-99215 for an established patient

CPT 99241-99245 for a consultation visit

If radiographs were taken, below is a list of some of the more common CPT codes that may be used to report dental x-rays:

70300 Radiologic examination, teeth; single view (i.e., periapical)

70310 Radiologic examination, less than full mouth (i.e., multiple periapicals)

70320 Radiologic examination, complete full mouth (i.e., FMX)

70328 Radiologic examination, temporomandibular joint, open and closed mouth; unilateral

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

70355 Orthopantogram (i.e., PanorexTM)

Medical Procedure Codes

In keeping with HIPAA’s Transaction and Code Sets Rule, medical carriers should accept dental codes (CDT) because they are part of the HCPCS (Healthcare Common Procedure Coding System) code set. However, not all carriers do at this time. One reason is that there is a hierarchy for reporting codes to medical carriers. If there is a specific medical CPT code that accurately describes the services performed, then the CPT code should be reported. If there is not a specific CPT code that 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 a HCPCS code or the dental “D” code.

Completing the Medical Claim Form

The medical claim form is used to communicate both diagnostic and treatment information to medical carriers. There are certain areas on the CMS 1500 claim form that must be completed in order to fully communicate dental trauma circumstances. One section is box 10. This is where one notifies the carrier that the services are related to an accident by checking the appropriate box for the type of accident that you are reporting (i.e., auto, work related, or other). Another section that must be completed is box 14. This is where one reports the date of the accident, which is essential for those carriers that have a time limit for coverage related to dental trauma. It is important to place the date of the actual accident in this box, not the date the patient was first seen in your office. You will have an opportunity to report additional information about the accident when entering the ICD-9 codes in box 19.

Trauma Related Diagnostic Codes

ICD-9 codes that are often used to code for trauma to a tooth include the following:

525.11 Loss of teeth due to trauma*

*525.11 cannot be listed as the primary diagnosis code. It is considered a manifestation code. Since the loss of teeth causes some level of edentulism, it is necessary to report the level of the edentulism as the primary code and the cause (loss of tooth due to trauma) as the secondary code.

The edentulism codes include the following:

525.40 Complete edentulism, unspecified

525.41 Complete edentulism, class I

525.42 Complete edentulism, class II

525.43 Complete edentulism, class III

525.44 Complete edentulism, class IV

525.50 Partial edentulism, unspecified

525.51 Partial edentulism, class I

525.52 Partial edentulism, class II

525.53 Partial edentulism, class III

525.54 Partial edentulism, class IV

Other ICD-9 Codes Used to Report Dental Trauma

802 Fracture of face bones (requires 4th digit)

802.8 Other facial bones, closed (i.e., alveolus)

802.9 Other facial bones, open (i.e., alveolus)

873.6 Other open wound of head, internal structures of mouth, no mention of complication (requires 5th digit)

873.60 Mouth, unspecified site

873.61 Buccal mucosa (open wound–inside of cheek)

873.62 Gum (alveolar process)

873.63 Tooth (broken) (fractured) (due to trauma)

873.64 Tongue and floor of mouth

873.65 Palate (open wound–roof of mouth)

873.69 Other and multiple sites

873.7 Open wound of head, internal structures of mouth, complicated (requires 5th digit)

873.70 Mouth, unspecified site

873.71 Buccal mucosa (open wound–inside of cheek)

873.72 Gum (alveolar process)

873.73 Tooth (broken) (fractured) (due to trauma)

873.74 Tongue and floor of mouth

873.75 Palate (open wound–roof of mouth)

873.79 Other and multiple sites

522 Diseases of pulp and periapical tissues (requires 4th digit)

522.0 Pulpitis (acute or chronic)

522.1 Necrosis of the pulp (death of pulp tissue)

Using E Codes

As mentioned earlier, box 10 must be checked to communicate that this is a trauma claim. E codes (external causes of injury and poisoning) follow diagnosis codes and are used to describe how the accident or trauma took place. There are hundreds of E Codes listed in ICD-9. Some of the more commonly used E codes are listed below.

EXTERNAL CAUSES OF INJURY—COMMONLY USED E CODES

E812.0 Motor vehicle accident with other motor vehicle (driver injured)

E812.1 Motor vehicle accident with other motor vehicle (passenger injured)

E812.2 Motor vehicle accident with other motor vehicle (motorcyclist)

E812.3 Motor vehicle accident with other motor vehicle (passenger on motorcycle)

E813.0 Motor vehicle accident with other vehicle, nonmotor transport (driver injured)

E813.6 Motor vehicle accident with other vehicle, nonmotor transport (pedal cyclist injured)

E814.7 Motor vehicle traffic accident involving collision with pedestrian (pedestrian injured)

E820.0 Nontraffic accident involving motor-driven snow vehicle (driver injured)

E821.0 Nontraffic accident involving other off-road (ATV) motor vehicle (driver injured)

E826.1 Pedal cycle accident (pedal cyclist injured)

E831.1 Injured in watercraft accident (watercraft propelled by paddle, oars, or small motor) (jet ski)

E849.0 Accident occurred at home

E849.3 Accident occurred at work

E849.4 Accident occurred at a place of recreation/sport

E849.5 Accident occurred on a street or highway

E849.6 Accident occurred at a public building (school, airport, restaurant, hotel, etc.)

E880.0 Fall on/from escalator

E880.1 Fall on/from sidewalk or curb

E880.9 Fall on/from other stairs or steps

E881.0 Fall from ladder

E881.1 Fall from scaffolding

E883.0 Accident from diving or jumping into water (swimming pool)

E883.9 Fall into other hole or opening in surface

E884.0 Fall from playground equipment

E884.9 Other fall from one level to another (tree)

E885.1 Fall from roller skates

E885.2 Fall from skateboard

E885.3 Fall from skis

E885.4 Fall from snowboard

E885.9 Fall from slipping, tripping, or stumbling (falling on moving sidewalk)

E886.0 Fall from collision, pushing, shoving (in sports)

E888.1 Fall striking other object

E917.0 Striking against or struck accidentally by objects or persons in sports without subsequent fall (e.g., struck by a hit or thrown ball)

E917.4 Struck by other stationary object without subsequent fall (e.g., bathtub, fence, lamppost)

E917.5 Struck by object in sports with subsequent fall (e.g., knocked down while boxing)

E917.9 Other striking against with or without subsequent fall

E920.4 Accident caused by hand tools and implements (e.g., hammer, axe, rake, shovel, etc.)

E960.0 Intentional injury (fight, brawl, or beating)

Global Surgical Package—Global Period

One of the major differences between billing dental carriers and medical carriers is the concept of the CPT “global surgical package” or “global period.” In the coding scenarios that follow, you will notice that several of the codes have a notation regarding global period. Within CPT all surgical procedure codes are assigned a global period during which the CPT definition of “surgical package” or “global period” applies. According to CPT, certain services are included in the global surgical package and cannot be billed separately to the patient and/or insurance carriers. These services include the following:

Local anesthesia,Subsequent to the decision for surgery, one related evaluation and management (E/M) encounter on the date immediately prior to or on the date of procedure (including history and physical),Immediate postoperative care,Writing orders,Evaluating the patient in the post-anesthesia recovery room, andTypical postoperative follow up care.

This means that the patient cannot be billed for any routine office visits during the postoperative period (as defined by the global period). It also means that an evaluation performed on the date of the surgical procedure may not be covered because some carriers will consider it global to the procedure.

Dental Trauma Coding Scenarios

Now that we have reviewed some of the fundamentals for reporting dental trauma claims to medical, let’s look at several case studies involving dental trauma. These cases provide examples of codes that may be used in each situation, as well as rules and exceptions regarding treatment plans and time tables. In each example, it is assumed that the doctor who originally saw the patient for treatment is treating the patient on subsequent visits.

Scenario #1: Dental Alveolar Fracture—Fall From Skateboard

While attempting a skateboarding trick, a twelve year old boy fell onto the sidewalk and fractured the bone between teeth #7 and #8. The patient’s mother was unable to reach her son’s dentist so she contacted your office to treat the child. He had never been seen in your office before. Since the patient was new to the practice, the dentist obtained a detailed medical history and performed a detailed examination. A panoramic x-ray was taken to evaluate the injuries. After completing the examination and reviewing the x-ray, the treatment plan was discussed with the mother and the child, and an informed consent was obtained. The dentist then placed arch bars and wires to repair the alveolar fracture. The boy was seen in the office for follow-up visits in the following weeks. A month later, the arch bars and wires were removed, and the fracture was healed.

Medical Procedure Codes (CPT/HCPCS)

99203-57 New patient evaluation (57 modifier=decision for surgery same day as procedure)

70355 Orthopantogram (panoramic x-ray)

21440 Closed treatment alveolar ridge (90 day global), OR

21445 Open treatment alveolar ridge (90 day global)

Routine postoperative office visits are not billable to the patient or carrier for a period of 90 days—they are considered a part of the global surgical package. Also note that the placement of the arch bars is inclusive to the fracture repair. (CPT code 21110 is only reported for application of interdental fixation for conditions other than fracture or dislocation and includes removal. In this case, since the fixation was placed for treatment of the fracture, 21110 should not be reported separately.)

Medical Diagnosis Codes (ICD-9)

802.8 Fx of other facial bones, closed (i.e., alveolus), OR

802.9 Fx of other facial bones, open (i.e., alveolus)

E885.2 Fall from skateboard

Scenario #2: Tooth Fracture—Car Accident

A 30 year old man was in a car accident involving another car, and his face made impact with the steering wheel, fracturing two front teeth into the pulp. He was seen in the local emergency room and was referred to your office for treatment by the emergency room physician. The patient was then seen in your office, and an expanded problem focused history (chief complaint and brief history of present illness; problem pertinent system review) was completed as well as an expanded problem focused exam (limited exam of the affected body area or organ system). Three periapical x-rays were taken and reviewed. After the examination was completed, the treatment plan options were presented to the patient, and informed consent was obtained. Root canals were performed on #8 and #9, with crown restorations to follow.

Medical Procedure Codes (CPT/HCPCS)

99242-25 Office consultation (25 modifier=E & M same day as minor procedure)

70310 Radiologic examination, less than full mouth (i.e., three periapicals)

D3310 Endodontic therapy (or CPT 41899 unlisted procedure, dentoalveolar structures)

Medical Diagnosis Codes (ICD-9)

873.63 Broken/fractured tooth (due to trauma)

E812.0 Motor vehicle accident with other motor vehicle (driver injured)

ICD-9 includes several categories of E codes for motor vehicle traffic and nontraffic accidents and a subsection of codes that identify the injured party (i.e., driver, passenger, motorcyclist, passenger on a motorcycle, occupant of a streetcar, rider of an animal, pedal cyclist, pedestrian, other specified person, or unspecified person). Examples can be found in the sidebar on page 11, and a complete list of E codes can be found in the latest version of ICD-9.

COB note: When treating a patient who has been in an auto accident, remember that the rules for insurance coverage vary from state to state. Check with the patient’s auto insurance carrier or your state insurance department to determine whether auto insurance or medical insurance is primary in your state.

Scenario #3:

Lacerations—Fall From Bicycle

A 16 year old girl (a long standing patient in your office) arrived with lacerations on her lip from her braces. She had been riding her bike in a state park and flipped over the handle bars after hitting a rock, landing face first on the ground. The dentist recorded a problem focused history (chief complaint; brief history of present illness) and performed an expanded problem focused exam. After completing the exam, it was determined that her injuries were limited to lacerations on her lower lip that required both simple and intermediate suturing techniques to repair. She was seen for a follow-up visit a week later, and the sutures were removed.

Medical Procedure Codes (CPT/HCPCS)

99213-25 Office visit, established patient (25 modifier=E & M same day as minor surgery)

12051 Intermediate repair 2.5 cm or less (10 day global period)

12011-51 Simple repair of superficial wounds of face, ears, eye lids, nose, lips, and/or mucous membranes 2.5 cm or less (10 day global period) (51 modifier=multiple procedures same day)

Suture removal and the postoperative visit are part of the global surgical package and are not billable to the patient/carrier.

Medical Diagnosis Codes (ICD-9)

873.43 Other open wound of head, face, without mention of complication

E826.1 Pedal cycle accident (the fourth digit [.1] describes the injured as the cyclist)

According to ICD-9, the term “complicated” includes lacerations involving delayed healing, delayed treatment, foreign body, or infection.

There are specific rules for coding lacerations under CPT. By CPT definition, wounds or lacerations are broken down into three distinct categories:

Simple repair is coded when the wound is superficial (e.g., involving primarily epidermis or dermis, or subcutaneous tissues without significant involvement of deeper structures, and requires simple one layer closure).

Intermediate repair includes the repair of wounds that, in addition to the above, require layered closure of one or more of the deeper layers of subcutaneous tissues and superficial (nonmuscle) fascia, in addition to the skin (epidermal and dermal) closure. Single layered closure of heavily contaminated wounds that have required extensive cleaning or removal of particulate matter also constitutes intermediate repair.

Complex repair includes the repair of wounds requiring more than layered closures, scar revision, debridement (e.g., traumatic lacerations or avulsions), extensive undermining, stents, or retention sutures. Necessary preparation includes creation of a defect for repairs (e.g., excision of scar requiring complex repair).

In order to correctly code for repair of a laceration keep the following in mind:

Wounds should be measured and recorded in centimeters.When multiple wounds are repaired, add together the lengths of those in the same classification (type of repair) and from all anatomic sites that are grouped together. Report just one code.When more than one classification of wound is repaired, list the more complicated one as the primary code and the less complicated as the secondary code with the -51 modifier.

Scenario #4: Avulsed Tooth—Struck by Golf Ball

During a round of golf, a 50 year old woman was struck in the mouth by a golf ball, partially avulsing tooth #26. The patient has been in your practice for many years. However, she has not been seen in your office for over three years. When she arrived at the office the dentist recorded a detailed history and performed a detailed examination of the patient. A panoramic x-ray was taken. After the examination was complete and a treatment plan was determined, the treatment options were presented to the patient and informed consent was obtained. The doctor removed the remaining part of the tooth after it was decided the tooth could not be saved through stabilization. A socket preservation bone graft was performed in preparation for an implant to replace the extracted tooth.

Medical Procedure Codes (CPT/HCPCS)

99203-25 New patient office visit (According to CPT guidelines, “A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years.”)

70355 Panoramic x-ray

D7140 Non-surgical extraction (or CPT 41899, by report)

D7953 Socket preservation bone graft (or CPT 21299, by report)

Future Procedure Code (CPT/HCPCS)

D6010 Dental implant (or CPT 21248)

Medical Diagnosis Codes (ICD-9)

873.63 Fractured tooth (avulsed in this case)

E006.2 Activities involving golf

Future ICD-9 Codes

525.xx Report the appropriate edentulism classification code

525.11 Loss of tooth due to trauma

525.21 Mandibular atrophy, minimal

In Summary

When submitting dental accident claims to a medical plan, your odds of success will increase considerably if you follow two simple rules:

Always contact each patient’s medical carrier to ask about its trauma coverage policies and time lines, andWhen communicating with medical carriers, whether by telephone or on the CMS 1500 claim form, be as detailed as possible. The more detail you can provide about the trauma incident and proposed treatment plan, the more accurate you will be estimating coverage.