May 2020 Volume LV Number 3

 
 
 
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Coding Corner

March 2020 Volume LV Number 2

The 2019 ADA Dental Claim Form is Now in Effect
 
In early June of 2019, the American Dental Association (ADA) released its new Dental Claim Form, effective as of its release date. The ADA Dental Claim Form was last updated in 2012 to incorporate the capability to apply diagnoses codes. The 2019 ADA Dental Claim Form consists of minor editorial changes to maintain consistency with the current HIPAA standard 837D v5010 Electronic Dental Claim Form.
 
The editorial amendments to the claim form can be found in the PDF below.
 
Conclusion
To avoid payment delays, always submit claims to payers using the most current claim form available. Contact your practice management software vendor to update to the 2019 ADA Claim Form. While the ADA Claim Form completion instructions should be followed, be aware that some payers have unique processing requirements (e.g., how  to report procedures performed on multiple teeth). Comprehensive 2019 ADA Dental Claim Form completion instructions are posted on the ADA’s website at https://www. ADA.org/en/publications/cdt/ada-dental-claim- form.
 
The following information highlights certain form completion instructions.
 
General Instructions
  1. The form is designed so that the name and address (Item 3) of the third-party payer receiving the claim (insurance company/dental benefit plan) is visible in a standard #9 window envelope (window to the left). Please fold the form using the ‘tick-marks’ printed in the margin.
  2. Complete all items unless noted other- wise on the form or in the instructions posted on the ADA’s web site.
  3. Enter the full name of an individual or a full business name, address and zip code when a name and address field is required.
  4. All dates must include the four-digit year.
  5. If the number of procedures reported exceeds the number of lines available on one claim form, list the remaining pro- cedures on a separate, fully completed claim form.
  6. GENDER Codes (Items 7, 14 and 22) – M = Male; F = Female; U = Unknown
Coordination of Benefits (COB)
When a claim is being submitted to the secondary payer, complete the entire form and attach the primary payer’s Explanation of Benefits (EOB) showing the amount paid by the primary payer. You may also note the primary carrier paid amount in the "Re- marks" field (Item 35).
 
Diagnosis Coding
The form supports reporting up to four diagnosis codes per dental procedure. This information is required when the diagnosis may affect claim adjudication when specific dental procedures may minimize the risks associated with the connection between the patient’s oral and systemic health conditions. Diagnosis codes are linked to procedures us- ing the following fields:
  • Item 29a – Diagnosis Code Pointer ("A" through "D" as applicable from Item 34a)
  • Item 34 – Diagnosis Code List Qualifier (AB for ICD-10-CM)
  • Item 34a – Diagnosis Code(s) / A, B, C, D (up to four, with the primary adjacent to the letter "A")
 
Place of Treatment
Enter the 2-digit Place of Service Code for Professional Claims, a HIPAA standard maintained by the Centers for Medicare and Medicaid Services. Frequently used codes are: 11 = Office; 12 = Home; 21 = Inpatient Hospital; 22 = Outpatient Hospital; 31 = Skilled Nurs- ing Facility; 32 = 
 
Nursing Facility
The full list is available online at https:// www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/PhysicianFeeSched/Downloads/Website- POS-database.pdf.
 
Provider Specialty
This code is entered in Item 56a and indicates the type of dental professional who delivered the treatment. The general code listed as "Dentist" may be:
A dentist is a person qualified by a doctor- ate in dental surgery (D.D.S.) or dental medi- cine (D.M.D.) licensed by the state to practice dentistry, and practicing within the scope of that license. 122300000X
 
  • General Practice 1223G0001X
  • Dental Specialty (see following list)
  • Dental Public Health 1223D0001X
  • Endodontics 1223E0200X
  • Orthodontics 1223X0400X
  • Pediatric Dentistry 1223P0221X
  • Periodontics 1223P0300X
  • Prosthodontics 1223P0700X
  • Oral & Maxillofacial Pathology 1223P0106X
  • Oral & Maxillofacial Radiology 1223D0008X
  • Oral & Maxillofacial Surgery 1223S0112X

Amalgam Separator Deadline Approaching Quickly – ADA Reminder!
 
Under a federal rule adopted by the Environmental Protection Agency in 2017, many dental practices will need an installed amalgam separator by July 14, 2020. A few practices may be exempt, but some of those that are still need to submit a form to affirm their exemption from the rule.
 
See the entire article in ADA News at https://www.ada.org/en/publications/ada-news/2019-archive/october/amalgam-separator-deadline-approaching- quickly. For more information or questions, please contact AAPD Dental Benefits Director Mary Essling at messling@aapd.org or (312) 337-2169.
 

Click here for a PDF version of this article.