September 2021 Volume LVI Number 5


Medical Filing Tips for Dental Accident Claims

September 2013 Volume XLIX Number 5

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 a person fractures a tooth while biting into a popcorn kernel, the restorative services are not likely to be covered under a medical policy. Additionally, 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. 


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 restoration 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 is critical. 


 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 
 The most commonly used medical evaluation and management codes (E & M) fall into one of the following categories: 
 Office or Outpatient Services: 
 New Patient 99201-99205 
 Established Patient 99211-99215 
 Consultations Office Consultations 99241-99245 
 Inpatient Consultations 99251-99255 
 Note that all evaluations and consultations start with the numbers "992_ _." 
 The FOURTH digit reflects the origin of the patient: 
 0 = New 
 1 = Established 
 4 = Referred 
 5 = Inpatient 
 The FIFTH digit reflects the level of difficulty, number of areas involved, and the time it takes to make a diagnosis. 
 1 = brief or problem focused 
 2 = expanded problem focused 
 3 = detailed 
 4 = comprehensive 
 5 = extensive, difficult diagnosis 
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) 


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. 


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. 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. 


ICD-9 codes often used to code for trauma to a tooth include: 
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


As mentioned earlier, box 10 must be checked to communicate that this is a trauma claim. E codes (external causes of injury) follow diagnosis codes and are used to describe how the accident or trauma took place.


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 
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 
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)


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 
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) 


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 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, and •   Typical 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.


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. 


While attempting a skateboarding trick, a 12-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. 


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.) 


802.8       Fracture of other facial bones, closed (i.e., alveolus), OR 
802.9       Fracture of other facial bones, open (i.e., alveolus) 
E885.2 Fall from skateboard 


When submitting dental accident claims to a medical plan, your odds of success will increase considerably if you follow two simple rules: 
1. Always contact each patient's medical carrier to ask about its trauma coverage policies and time lines, and 
2. When communicating with medical carriers, whether it be 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.