Dental and Medical Billing Guidelines for Frenectomies

Dental and Medical Billing Guidelines for Frenectomies

Frenectomy procedures are performed primarily on infants, and it involves the removal of one or both frena from the mouth. As per the statistics given by the American Academy of Pediatric Dentistry, the number of frenotomy/frenectomy procedures performed is growing with a 90 percent increase in recent years. As the ADA (American Dental Association) changes the CDT (Current Dental Terminology) codes frequently, dental practices are required to adopt the changes and ensure accuracy in their claims. A dental billing company can help with complete and accurate documentation of dental procedures.

Frenectomy – A Covered Dental Procedure;

Frenectomy is considered medical in nature due to the following two reasons:

  • There is a problem feeding the newborns
  • It is required to correct congenital malformation( Ankyloglossia)

It implies that a frenectomy is medically necessary and is accompanied by the following symptoms, according to provcomm.ibx.com:

  • Difficulty feeding/eating
  • Difficulty chewing ( mastication)
  • Difficulty swallowing
  • Speech impairment or difficulty with articulation

The procedures used to treat the lingual frenum (other than for ankyloglossia), the labial frenum and the buccal frenum are considered dental procedures. Dental practices have to take note of the fact that they are not covered under medical plans and are considered benefit contract exclusions.

CPT Codes for Frenectomy or Frenotomy

  • 41010

In this procedure, the provider makes an incision in the lingual frenum, a membranous ridge under the tongue, to allow greater movement of the tongue in patients with ankyloglossia.

  • 41115

In this procedure, the provider makes an incision at the base of the tongue and excises the frenum.;

  • 40806

The provider incises the labial frenum, the tag of tissue in the center of the upper or the lower lip that attaches the lip to the gums of the patient. The provider does not remove the frenum. The provider commonly performs this procedure to release a tight frenum and its surrounding tissues.

  • 40819

In this procedure, the provider removes the labial or buccal frenum, each of which is a membrane structure in the mouth. Labial refers to the lip and buccal refers to the cheek.

  • 41115

In this procedure, the provider makes an incision at the base of the tongue and excises the frenum.

ICD-10 Codes

  • Q38.1

Ankyloglossia

For feeding difficulties:

  • R63.3 – Feeding difficulties
  • P92.5- Neonatal difficulty in feeding at the breast
  • P92.8- Other feeding problems of newborn
  • P92.9- Feeding problem of newborn, unspecified

For childhood articulation problems:

  • F80.0- Phonological disorder
  • F80.89-Other developmental disorders of speech and language
  • F80.9- Developmental disorder of speech and language, unspecified

CDT Codes

The below-mentioned codes are newly added CDT codes and are effective from 01/01/2021.

  • D7961- Buccal / labial frenectomy (frenulectomy)
  • D7962- Lingual frenectomy ( frenulectomy)

Guidelines to Follow While Claiming Dental Insurance

  • To facilitate coverage and payment, submitting the claim with x-rays alone is insufficient.
  • The above-mentioned codes are applicable only if the procedure involves removing a patient’s frenum.
  • Carefully consider the patient’s plan limitations and exclusions.
  • The claims of this procedure are limited to once per lifetime, per tooth.
  • If connective tissue graft or pedicle graft is reported on the same visit as the frenectomy, the frenectomy is considered inclusive with no additional payments.
  • According to dentistryiq.com, a narrative should also be included which indicates the following:
    • Amount of gingival recession in millimetres
    • The severity of gingival inflammation
    • The level of sensitivity
    • Bleeding on probing
  • The claim form should be accompanied by pre-op and post-op x-rays in addition to periodontal charting.

General Guidelines for Medical Billing for Dental Surgery

According to dentalproductsreport.com, to successfully place dental claims, the following has to be accurately documented:

  • The primary presenting situation
  • Any secondary, supporting diagnosis
  • The diagnosis code for the treatment
  • Surgical pre-authorization
  • Medical necessity, in the form of a letter of medical necessity
  • Support from the patient’s primary care physician, in the form of a supporting letter of medical necessity
  • The procedures performed at each surgery location

This is vital information that is required by the medical insurance company to get a comprehensive understanding of the care provided.

  • Prior-authorization

Frenectomy procedures require a pre-authorization. The insurer has to be contacted via phone to explain the procedure and the date. Reimbursement claims will be rejected if pre-authorization is not obtained.

  • Verification of insurance

Dental eligibility verification is essential to gather information about the coverage for this surgery. The following information must be collected from the patients first:

  • Name of the primary insured
  • Social security number of the primary insured
  • Insurance carrier
  • ID number
  • Group number
  • Contact details of the insurance company like phone number, web address and residential address for submitting claims.
  • Proving medical necessity

A frenectomy is performed as a medically necessary procedure. Accurate medical coding is vital. Coding should inform the payer that the procedure was performed and the reason that the patient’s concern was medical rather than just a dental problem

  • Accurate coding

Appropriate ICD-10 codes and CPT codes have to be incorporated in the Letter of Medical Necessity. According to Dental Practice Management, dental practices have to limit themselves to entering only four diagnostic codes in the Letter of Medical Necessity. The most important procedure should be listed first, followed by the procedures of a lesser importance.

  • Documenting and submitting the claims

After the dental surgery, the next important step is filling in the claims submission form correctly. A thorough look over the forms is necessary to identify typos or missed information. The claim must be submitted to the insurer with appropriate documentation. Lab or diagnostic imaging studies are also to be submitted along with the claims as supporting documents.

Compared to billing for other medical specialities, dental billing is complex. An experienced dental billing company can help dental practices to improve dental billing collections and ROI, particularly for services like frenectomies where prior authorization is required.

How Can Outsourcing Of Back Office Functions Help A Dental Office During Worker Shortage

How Can Outsourcing Of Back Office Functions Help A Dental Office During Worker Shortage

During the public health emergency prompted by COVID-19, many states issued orders instructing dental offices to cancel or postpone elective or non-urgent procedures that could be delayed without much risk to the patient’s health. In April 2020, CNBC reported that the health care sector lost a record 1.4 million jobs and that dental practices accounted for over half a million job cuts. According to the American Dental Association, all but 3% of dental offices nationally were shut down except for emergency appointments in March last year and nearly 9 out of 10 had laid off staff. Many practices resorted to teledentistry to deliver virtual care and dental billing companies played a key role in helping them manage their revenue cycle.

Dental and medical offices across the U.S. are now reopening in a phased manner based on recommendations and mandatory safety and health standards issued by the Occupational Safety and Health Administration. With the worker shortages driven by the COVID-19 pandemic, it would be highly beneficial for dental practices to outsource their back office duties as they navigate the challenges of reopening.

2020 IDA Survey reveals Major Dental Office Staffing Concerns

Data released by the Indiana Dental Association (IDA) in July 2020 provides a clear picture of the negative impact that the COVID-19 pandemic has had on dental practices in the state. At the time of the IDA survey, many dentists and dental offices were still suffering from acute and sustained financial losses due to the COVID-19 pandemic. Dental offices had been experiencing staffing shortages prior to the pandemic and many reported worsening of the situation. Key findings of the IDA 2020 survey include:

  • Up to 60% of dentists reported their office is still not operating at full capacity
  • Many dentists reported trouble filling positions
  • 37% of dentists reported that some of their staff quit or retired
  • 17.6% reported having trouble filling office staff positions

The problems experienced by practices due to staffing challenges included

  • not being able to schedule as many treatments, and
  • the office failing to run smoothly

The reasons mentioned cited for not being able to find dental staff were:

  • Fear of returning to works
  • Competition for qualified staffs
  • Unemployment benefits

In the new normal, dental practices need to review their staffing practices. According to a 2020 Dental Economics article, this may mean not employing as many staff as they previously did, changing employees’ duties, reducing hours or pay, and so on. The goal should be to keep the business functioning. In this situation, outsourcing dental back office duties can benefit both the practice and patients.

Benefits of Dental Back Office Outsourcing during the Pandemic

Dental practices can reemploy furloughed or temporarily laid off employees, but staffing levels should align with the level of business to ensure expenses are in line with budgeted costs and revenue. This means that not everyone, including back office staff, can be brought back. In the circumstances, outsourcing the back office to a dental billing company is a practical solution to rein in costs while promoting better patient care and practice efficiency. Experienced service providers can take care of the entire billing cycle, from the front desk and dental eligibility verification to patient scheduling, dental billing and coding, accounts receivable (AR) management, and more.

Dental insurance verification services provided by outsourcing companies involve verifying coverage benefits for both new and existing patients before they are treated. The process involves verifying the following details for each patient:

  • Effective coverage dates
  • Waiting periods
  • Maximums and deductibles
  • Treatment history
  • Benefits used to date
  • Type of plan and fee schedule
  • Claim submission information (address, phone number, payor ID etc.)
  • Coverage percentage by category
  • Implant and orthodontic coverage
  • Frequencies, limitations, and exclusions
  • Missing tooth clause, and more

With a dedicated dental insurance verification expert managing this time-consuming and often complex task, dentists can rest assured that claims go out accurately and are paid in a timely manner. Proper insurance verification means reduced risk of denials and happier patients and is one of the most important aspects when it comes to improving the practice’s bottom line.

Patient scheduling involves optimizing the appointment system to maintain a steady patient flow. Managing patient scheduling can be a challenge when adhering to COVID social distancing mandates. Outsourcing companies can provide efficient online patient scheduling and appointment management solutions to help dental practices improve patient flow.

A dental billing company will work on your software to manage your coding and invoicing. Billing specialists stay up to date with coding changes and industry regulations and can ensure accurate claim submission. They will ensure you have an efficient AR operation that gets you paid accurately and faster.

To sum up, outsourcing back office duties during the COVID-19 pandemic can help improve dental practice efficiency and improve the patient experience. It will allow dentists to focus better on patient care and their (limited) staff to save valuable time that would go into verifying patient coverage. Outsourcing insurance verification and authorization to a specialist will also ensure eligibility review before the appointment, which is crucial to prevent claim denials due to eligibility problems.

The IDA survey reported that dental practices suffered loss of income due to staffing challenges associated with inability to meet demand, patient fear resulting in reduced demand, and new clinic protocols resulting in lower productivity. It’s clear that in these challenging times, dental practices need to find cost-effective ways of managing their operations. A reliable dental billing service provider can help them overcome back office staffing shortage and navigate office reopening more easily.

October Is National Orthodontic Health Month

October Is National Orthodontic Health Month

The American Association of Orthodontists (AAO) has designated October as National Orthodontic Health Month. This month is dedicated to raising awareness about the benefits of orthodontic treatment and the importance of good oral health. Orthodontics aims at improving the appearance of the teeth, making it easier to clean the teeth and how they work by straightening or moving teeth to improve their appearance. This form of dentistry is ideal to straighten crooked teeth, close wide gaps between the teeth, improve speech or chewing ability, boost the long-term health of gums and teeth, and treat an improper bite. It mainly treats malocclusion and helps to correctly position the teeth when the mouth is closed. Left untreated, such issues can result in more serious oral health problems such as tooth decay, tooth loss, gum disease or even jaw problems.

People consider these treatments for cosmetic purposes as well as to improve oral functions. AAO has reported that more than 1.6 million adults in North America are receiving orthodontic treatment from AAO orthodontists. Medical dental devices used for this treatment include headgear, plates, braces, fixed or removable space maintainers, aligners, palatal expanders, retainers, splints and more. To assess the state of the person’s teeth, the orthodontist may carry out a clinical examination, take x-rays of the teeth and jaw and make plaster models of the teeth.

While a dentist specializes in the broader area of oral health, an orthodontist deals specifically with the bite and straightness of teeth. Experienced dental billing companies can provide the challenging medical coding task, as they are up to date with the changing coding standards and insurance guidelines. It is important to include the correct CDT, ICD, HCPCS and CPT codes on the medical claims, as any coding errors could lead to claim denials. For most insurers severe malocclusion requires prior authorization, while cleft palate requires expedited authorization (EPA).

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Some of the ICD-10 and CDT codes related to orthodontic treatments are –

CDT

  • D8010 Limited orthodontic treatment of the primary dentition
  • D8020 Limited orthodontic treatment of the transitional dentition
  • D8030 Limited orthodontic treatment of the adolescent dentition
  • D8040 Limited orthodontic treatment of the adult dentition
  • D8050 Interceptive Orthodontic treatment of the Primary Dentition
  • D8060 Interceptive Orthodontic treatment of the Transitional Dentition
  • D8070-Comprehensive orthodontic treatment of the transitional dentition
  • D8090-Comprehensive orthodontic treatment of the adult dentition
  • D8210 Removable appliance therapy
  • D8220 Fixed appliance therapy
  • D8660 Pre-orthodontic treatment visit
  • D8670 Periodic orthodontic treatment visit (as part of contract)
  • D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s))
  • D8690 Orthodontic treatment

ICD-10

  • K00.0 Anodontia (missing teeth)
  • K00.1 Hyperdontia (supernumerary teeth)
  • K00.2 Abnormalities of size and form
  • K00.3 Mottled teeth
  • K00.4 Disturbances of tooth formation
  • K00.5 Hereditary disturbances in tooth structure, not elsewhere classified
  • K00.6 Disturbance of tooth eruption
  • K00.8 Other specified disorder of tooth development and eruption
  • K00.9 Unspecified disorder of tooth development and eruption
  • K05.20 Aggressive gingivitis, plaque induced
  • K05.21 Aggressive gingivitis, non-plaque induced
  • K05.22 Aggressive gingivitis, generalized
  • K05.30 Chronic periodontitis, unspecified
  • K05.31 Chronic periodontitis, localized
  • K05.32 Chronic periodontitis, generalized

Completing a full dental eligibility verification before the patient’s date of service is a crucial process. Before providing treatment, practices must ensure that the patient is eligible for orthodontic benefits. Some dental plans restrict benefits to children, but others provide benefits to adults. Other important steps in orthodontic billing include coordination of benefits (COB) and completion of the insurance form.

Medicare Billing for Dentists – Best Practices for Optimal Reimbursement

Medicare Billing for Dentists – Best Practices for Optimal Reimbursement

Medicare does not cover most dental services. In an outpatient setting, even if an excluded service is a complex or difficult primary procedure, Medicare will not cover it. Medicare Part A will pay for dental services if they are inpatient hospital services provided in connection with dental procedures that require hospitalization due to an underlying medical condition and clinical status or the severity of the dental procedures. Knowing what Medicare covers and doesn’t cover and ensuring proper billing and coding to meet payer requirements is essential to obtain optimal reimbursement. A dental billing company can help with this.

  • Know Medicare Dental Coverage: Generally, original Medicare (Part A and Part B) does not cover routine dental items and services connected with the care, treatment, removal, filling, or replacement of teeth, dental devices such as dentures or plates, or structures directly supporting the teeth.

    Medicare will pay for:

    • Dental services that are an integral part of a covered service
    • Extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw
    • Oral examinations, but not treatment, preceding kidney transplantation or heart valve replacement, under certain circumstances. These examinations would be covered under Part A if performed by a dentist on the hospital’s staff or under Part B if performed by a physician
    • If specific requirements are met, certain dental items and services, such as dental sleep apnea devices, may be covered in certain geographic areas through local coverage determinations
    • Whether services as the administration of anesthesia, diagnostic x-rays, and other related procedures are covered depends upon whether the primary procedure being performed by the dentist is itself covered. For instance, an x-ray related to the reduction of a fracture of the jaw or facial bone is covered, but a single x-ray or x-ray survey taken in connection with the care or treatment of teeth or the periodontium is not covered (uhc.provider.com).

    Medicare Advantage (Part C) plans are private health insurance plans that offer some dental benefits and may cover routine preventive care, such as cleanings, X-rays, and regular exams, either partially or in full, and also provide some coverage for extractions, root canals, dentures, crowns, fillings, and treatment for gum disease.

  • Know When to Enrol in Medicare: Dentists who provide Medicare Part B covered items and services need to either enrol in Medicare or formally opt out. Even if they don’t provide Medicare Part B covered items and services, they need to either enrol or formally opt out if they order covered clinical laboratory services, imaging services, or DMEPOS for patients who are on Medicare.
  • Have the Patient Sign the ABN if Medicare will not Cover a Service/Item: If Medicare does not cover a service/item that the patient wants, it is important that the patient signs the ABN (Advanced Beneficiary Notification) form. This confirms that the patient understands that Medicare will not cover the service/item and agrees to pay out of pocket for it. ABN forms are not necessary for things that Medicare typically doesn’t cover such as routine dental services like cleaning, root canals, etc.
  • Know Documentation Requirements: Dentists should provide documentation supporting along with the claims. This includes the ICD-10 codes to support the medical necessity for the surgery in an inpatient setting. Claims without such proper documentation will be denied. If the dental procedure performed is not the primary procedure, documentation of the primary procedure should be included in the patient’s medical records. CPT/HCPCS procedure codes should be used on medical claims to bill the medical insurance. For many procedures, dentists may need to provide their SOAP notes to the Medicare insurer for obtaining a pre-authorization approval or processing a claim.
  • Perform Dental Eligibility Verification: Verifying coverage and benefits is important for the practice and also for patients. Many older patients have a Medicare Advantage Plan that pays for dental services, since original Medicare doesn’t usually cover any dental services. While routine dental services would be considered additional coverage, Medicare Advantage dental services may vary from plan to plan. Dental eligibility verification should cover all major insurance eligibility aspects such as demographic information and policy date as well as coverage percentage by category, tooth cleanings, crowns, build-ups, tooth grafting coverage, tooth implant coverage, and x-ray frequencies and out-of-pocket requirements. Prior authorization should be obtained if needed.
  • Ensure Correct Medicare Billing: Dental practices are responsible for submission of accurate claims. Medicare makes coverage decisions accurately based on the code or codes that correctly describe the health care services provided. Billing dental services correctly is critical to ensure the claims are processed correctly and inaccurate payments are not made.
  • Use the Patient’s MBI: In 2020, Medicare removed SSNs from all Medicare cards and replaced them with a new, randomly generated Medicare Beneficiary Identifier MBI. The MBI should be used for all Medicare transactions. As Medicare beneficiaries can ask to change their MBI if the number has been compromised, providers should verify their patient’s MBI when they come for care.
  • Wait to Charge/collect the Medicare Part B Deductible: Medicare Part B beneficiaries have to pay a deductible before Medicare will provide them with coverage for additional costs. Medicare-participating providers are authorized to bill the beneficiaries for deductibles. However, collecting deductibles up front from Medicare recipients may not be a good practice as an incorrectly collected deductible may be considered over-collection and deemed program abuse. Dentistry IQ advises dentists not to collect the deductible amount from a patient until they can confirm whether or not it has been met. All deductibles should be properly recorded and any improper deductibles refunded.
  • Stay up-dated with Industry Rules and Regulations: To ensure correct billing, providers need to stay up to date with changes in industry rules and regulations. For e.g., the Stark Law or Physician Self-referral Law has been modernized in 2021 “to remove potential regulatory barriers to care coordination and value-based care”. Likewise, being aware of Local Coverage Determinations, National Coverage Determinations is crucial as these documents provide coverage information and determine whether services are reasonable and necessary on certain services offered by participating providers.

Partnering with an experienced dental billing service provider is the best way to optimize Medicare billing, collect proper reimbursement and boost patient satisfaction.

Save Time and Money by Outsourcing Dental Eligibility Verification

Save Time and Money by Outsourcing Dental Eligibility Verification

Dental Eligibility VerificationAccording to a report in Dentistry IQ, dental insurance checks make up approximately 50% of the income of most dental practices. It is therefore essential that dentists have dedicated and efficient insurance management strategies in place. One of the most important aspects of insurance management is dental eligibility verification. Failure to check patients’ eligibility or the use of incorrect eligibility data are the main reasons for denied dental claims. For new patients, all insurance information should be collected and verified before their visit. Eligibility verification is critical for existing patients too, as patient benefits may change with changes in insurance plans. Outsourcing benefits verification is an ideal strategy to save time and money.

Practices need to communicate with patients in advance about their coverage as most people do not understand their dental benefits. They should be informed as to whether the dentist is a contracted provider for their plan. Dental insurance verification is also essential for providers to get paid. However, verifying insurance can be a big headache for the dental front office. The staff will need to call up the company and spend hours trying to get to the insurance representatives to provide the necessary information. The process will involve verifying plans for new patients, emergency patients, and existing patients. Considering these challenges, practices can benefit immensely by hiring an insurance verification specialist.

Dental insurance verification experts will ensure that patients’ health care benefits cover required procedures before services are provided. This will help improve claim accuracy as well as patient payment responsibilities and satisfaction. These professionals have extensive experience working with insurance companies, and are knowledgeable about different types of coverage and policies.

In order to confirm insurance eligibility of new patients, they will first collect the following information:

  • Patient’s name and date of birth
  • Name of the primary insured
  • Social security number of primary insured
  • Insurance carrier
  • ID number
  • Preauthorization
  • Group number
  • Contact information for the insurance company such as phone number, website and address for claim submission

Once they have collected this insurance information, they will contact the insurance company directly and speak to the insurance rep to verify the following:
Dental Eligibility Verification

  • Whether the patient is covered by the insurance
  • Insurance coverage effective dates
  • In-network or out-of-network coverage
  • Whether they need pre-authorization and/or a referral
  • Whether service(s) to be provided to the patient are covered
  • Coverage percentages breakdown
  • If annual maximum has been met, and how much remains
  • Frequency limitations of exams and x-rays
  • Crown frequency
  • Amount of co-pay for services, if any
  • Deductible amount, and if the deductible been met for the year

Insurance verification specialists also help dental practices update their returning patients’ records. As personal information such as address, contact information, employment, and insurance coverage may change over a short period of time, it is important to verify existing patients’ personal information before each office visit. If there is a change in the insurance of a returning patient, dental eligibility will be checked prior to the office visit.

The benefits of outsourcing dental insurance verification to an experienced service provider are:

  • Eliminates eligibility and benefits-related denials
  • Prevents delayed payments and underpayments
  • Reduces delinquent accounts
  • Saves the time that would go into analyzing and chasing denied claims
  • Provides a comprehensive understanding of the patients’ copayments and deductibles
  • Reduces stress and improves the efficiency of the front office
  • Frees up staff to focus on other important matters
  • Allows the practice to provide the patient with a more accurate estimate before treatment starts
  • Improves collections at the time of service
  • Allows accurate billing of different insurance companies
  • Improves practice revenue and productivity

Dental insurance verification services help providers to be transparent about copayments with their patients. A Physicians Practice article points out that the insurance industry has evolved to place greater financial responsibility on patients. Patients want to know the cost of the services being provided before they are billed for them. Verifying dental eligibility promotes healthcare cost transparency, prevents surprises on dental bills, and improves patient loyalty.

If you are considering outsourcing dental insurance verification, choose a company that can provide personalized services to suit your needs. Reliable companies can provide centralized dental information verification and management on their software or yours. They will verify benefits by calling up the insurance company and by visiting their websites and will contact patients for additional information, if necessary. They will work with your staff to conduct the operation smoothly without affecting your operational efficiency. With a capable service provider, your practice will be assured of accurate information at the start of the claims process and can experience fewer returned claims due eligibility issues, which will improve your bottom line.