Carol Tekavec, RDH
Two of the most common procedures performed in a dental office are radiographs and exams (now termed evaluations according to the ADA CDT-2). Coding for these everyday services should be simple. However, many offices run into problems when working with patients` insurance carriers.
If your office is committed to helping patients receive their best possible benefit, familiarity with common benefit restrictions and guidelines can be useful. Although patients should receive whatever services they require and offices should be paid whatever the procedures are worth, knowing what insurance might cover helps us help our patients pay their bills. (Remember, each insurance carrier will have its own policies.) What follows are typical guidelines for many U.S. carriers:
00150-Comprehensive Oral Evaluation This code replaces the former "new patient exam" Code 00110. It includes complete evaluation of all hard and soft tissues, cancer exam, and periodontal screening or comprehensive probing.
Use of this code is appropriate for both general practitioners and specialists. It usually is a benefit once every three years.
00120-Periodic Oral Evaluation This code describes our typical "recall exam." It also includes a periodontal screening or comprehensive probing. It usually is a benefit once in a six- month period.
00140-Limited Oral Evaluation - Problem-Focused This code replaces the former "emergency exam" Code 00130. It describes an evaluation at a not-regularly-scheduled appointment. It typically is paid once in a six-month period, but is not paid when performed on the same date that another treatment is finalized. It also eliminates payment for Codes 00150 and 00120 for six months.
00160-Detailed and Extensive Oral Evaluation - Problem- Focused, By Report This is a new code for a detailed, problem-focused exam. It includes visual, charting, periodontal-probing, diagnosis, and extensive treatment-planning. It is appropriate for patients with systemic disease, perio-prosthetic problems, or TMJD. If it is a covered benefit, it will be paid once every three years.
The primary stipulation to remember when coding exams is that most insurance plans will cover only two exams of any type during one year, regardless of how many exams the patient needs. With this in mind, it can be a practice-booster to avoid billing insurance for an emergency exam for a patient. Instead, simply bill for the actual treatment performed. (Normally, we want to convert emergency patients into regular patients.)
When the emergency patient returns for a complete exam, the higher paid, "new patient" Code 00150-Comprehensive Oral Evaluation, still will be a benefit, because we did not "use up" one of the two paid exam codes for the year. (Patients appreciate the help and will be more inclined to accept treatment and refer friends.)
Radiographs What constitutes a Code 00210-Intraoral Complete Series? For insurance purposes, it is typically seven or more periapicals and any additional bitewings (not the 18 films we normally consider it to be). This means that when seven or more PAs are taken at any one appointment, insurance carriers frequently will change PA Codes 00220 and 00230 to the complete series code. When a complete series is billed, bitewings may not be a covered benefit again for six months and panographs may not be a benefit for three years.
Many carriers interchange Codes 00210-Intraoral Complete Series and 00330-Panoramic Film. One will be paid, but not both, in any three-year period. If both are required, it enhances patient trust to inform the patient of the fact that one service will not be a covered benefit before the patient receives your bill. Eliminating surprises on the patient`s Estimate of Benefits inspires confidence.
On certain patients, many offices are using the "Updegrave" seven verticalbitewing technique. When this is done, it can be coded 00274-Bitewings - Four Films, 00220-Intraoral Periapical - First Film, and 00230-Intraoral Periapical - Each Additional Film (2x).
Carol Tekavec, RDH, is the author of two insurance-coding manuals, co-designer of a dental chart and a national lecturer. Contact her at (800) 548-2164 or at www.steppingstonetosuccess.com.
