November 2016 Volume LI Number 6
AAPD Stands Behind Members on Insurance Matters
Recently, we had a member call reporting that Delta Dental of California denied services for code denied D7270 tooth re-implantation and/or stabiliza- tion of accidentally evulsed or displaced tooth because it was performed on a primary tooth.
AAPD contacted Delta Dental of California na- tional dental director and this was their response:
Our pediatric dental consultant reviewed this case and the radiograph originally submitted with the claim. His evaluation found that the tooth has a complete mid- line root fracture. Our consultant’s opinion is that the prognosis is poor as the fracture is very close to the ridge and the fragments were not well approximated. Addi- tionally, he cited a statement from the AAPD Guideline on Management of Acute Dental Trauma that avulsed primary teeth should not be replanted because of the potential for subsequent damage to developing permanent tooth germs. So the determination is that this is not approved for payment. Our pediatric dental consultant will contact Dr. ____ to discuss the specifics of this case and the determination.
This case has brought to our attention a disconnect between our system, policies and processes. We acknowledge that the letter dated 8/12/16 from ____ in our Correspondence Dept. to Dr. _____ was inaccurate in stating that "D7270 is for permanent teeth." Our system is set up to allow procedure D7270 on permanent teeth only due to the very low utilization of this code for primary teeth. Our process should have been to forward Dr. ____’s claim for re-evaluation of D7270 for the primary tooth. As with any service, we will consider on re-evaluation if the service was justified. In this instance, Dr. _____’s request was handled as an inquiry rather than being forwarded as an appeal or request for re-evaluation. We are evaluating potential updates to our system, processes, and communication with providers to allow D7270 on primary teeth when appropriate.
AAPD greatly appreciates Delta Dental of California’s efforts in researching this claim denial and acknowledging Delta Dental CA’s incorrect rationale for denying the claim in the EOB. We are pleased to know that Delta Dental will be making revisions to its EOB communication with providers to allow D7270 on primary teeth when appropriate.
For help with insurance matters, please contact Dental Benefits Director Mary Essling at messling@ aapd.org or (312) 337-2169.
Behind the Code
Code D9994 Recommended for Documenting Interpreter and Translator Services
Beginning Jan. 1, 2017, the new dental case management and patient education code D9994 will be the code the AAPD recommends dentists use when billing plans for providing patients with language assistance services or documenting these services.
Section 1557 is the part of the Affordable Care Act that prohibits entities that receive federal financial assistance from discriminating on the basis of race, color, national origin, age, disability and sex. Providing language assistance at no cost to patients with limited English proficiency is one of the many provisions of the final rule on Section 1557.
Compliance requirements under the final rule include requiring covered entities to "take reasonable steps to provide meaningful access to individuals with limited English proficiency eligible to be served or likely to be encountered" as well as providing qualified interpreters and translators. Individuals with limited English proficiency may not be charged for language assistance services; the final rule does not require plans to modify fee schedules to reimburse providers for the service.
According to the Code on Dental Procedures and Nomenclature, Code D9994 applies to any "individual, customized communication of information to assist the patient in making appropriate health decisions" and is "designed to improve oral health literacy, explained in a manner acknowledging economic circumstances and different cultural beliefs, values, attitudes, traditions and language preferences, and adopting information and services to these differences, which requires the expenditure of time and resources beyond that of an oral evaluation or case presentation."
The AAPD, as always, prompts members that the existence of a CDT Code is not a guarantee of reimbursement for the service by a third-party payer; and also notes that Health Insurance Portability and Accountability Act only requires a thirdparty payer to accept a CDT Code that is valid on the date of service, and does not mandate coverage. Using this CDT Code documents the provision of the service, regardless of payment considerations.
For more information, please contact Dental Benefits Director Mary Essling at firstname.lastname@example.org or (312) 337-2169.
Prospective Possibilities for Coding and Income Potential
Potential opportunities to bring in income can be ignored when billable services are not submitted for reimbursement. Overutilization of a code/service can also lead to an increased risk of an audit and/or a request for refunds. It always helps to identify areas where there may be an increased risk of coding errors or a potential for increased reimbursement requests. For these identified codes, supporting documentation is imperative. Visit www.pediatricdentistrytoday.org to read the full article.
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