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Do You Understand Medicare
May 21st, 2019
By Christine Taxin | Published May 21st, 2019 - Last Review/Update May 22nd, 2019
Even though we may think we truly understand what it means to be a participating provider, Medicare doesn’t quite work the way that other insurance plans do. Far too many providers do not understand the difference and get into hot water. To further complicate matters, the rules are different for ...
In the next 10 years, what is the biggest change dentistry will experience?
FW: We all know healthcare in the U.S. is changing rapidly. Dentistry is no exception. My opinion is that several big changes are forthcoming. Most often, I think about changes that benefit patients and/or providers. Here are three ...
By Christine Taxin | Published February 19th, 2019
The ADA has forms in over 26 lanuages available to purchase. You also need specific forms for all of the procedures. Even working with patients who are pregnant needs to have a consent with a specialty and collaboration with medical providers. I am showing you one of the forms...
Wolters Kluwer provides unit and package pricing for multiple drug price types: Average Wholesale Price (AWP), Wholesale Acquisition Cost (WAC), Direct Price (DP), Manufacturer's Suggested Wholesale Price (SWP), Centers for Medicare & Medicaid Services, Federal Upper Limit (CMS FUL), Average Average Wholesale Price (AAWP), Generic Equivalent Average Price (GEAP). Average...
By Find-A-Code | Published May 9th, 2018 - Last Review/Update August 2nd, 2018
Preventive Medicine Topics Page
Dental Caries in Children
Procedure Codes 99188: Application of topical fluoride varnish by a physician or other qualified health care professional
ICD-10-CM 99188: No specific diagnoses
Frequency 99188: No specific frequency guidelines
Additional Information 99188
Covered for children from birth until their seventh birthday
Find-A-Code™ - Preventive Services - The information ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published April 30th, 2018
Is it true that medical benefits are only accessible by physicians? This is NOT True! Perhaps you have been told it is illegal for a dentist to bill a patient’s medical insurance, this is erroneous information. In fact, the Accountable Care Organization’s objective is to provide better management of care ...
Proper record keeping and documentation is not only essential for today’s dental practitioner, but is also required by law. Moreover, correct, current and accurate records directly enhance patient care by enabling the dentist to plan treatments, monitor progress, and provide essential notations. Clear and concise treatment plans, medical alerts, and ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published April 12th, 2018
When a Dental provider is treating a Medicare Beneficiary, it is important to get a copy of the Medicare card to verify the patient's medical benefits, provider eligibility and claims address/submission prior to submitting a claim. CMS is in the process of changing Medicare Policy Numbers, so you may see ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 1st, 2018
When billing for dental procedures you need to identify the exact tooth and/or location in the oral cavity. Qualifiers are used to report the location and tooth number. When billing procedures on teeth and the oral cavity, the JP qualifier is used to identify the tooth number(s) and the JO ...
Dental and Medical- Controlled Substance Awareness
January 29th, 2018
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published January 29th, 2018
As an effort to cut down on opioid abuse and related crimes, in August of 2017 the Attorney General Sessions established a new Department of Justice (DOJ) section called “Opioid Fraud and Abuse Detection Unit”. Due to the serious public health issue and drug overdose deaths, this unit was established and ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 28th, 2017
Once a patient has been evaluated for symptoms associated with sleep apnea, testing is ordered to identify severity and determine treatment.
There are several types of sleep tests, but coverage is based on meeting the criteria for Type I (inpatient facility based) or Type II-IV and Other (home-based sleep tests). All ...
Moderate Sedation Services - CPT has 6 Codes to One Dental Code
December 28th, 2017
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 28th, 2017
When billing a medical code instead of the dental code D9223 -Deep sedation/general anesthesia - each 15 minute increment, consider the following medical codes: (Be sure to review the AMA guidelines to see if they fit the procedure you are doing). If a dental office is doing conscious sedation for a patient ...
By Christine Taxin | Published November 30th, 2017
Is the provider non-par or has he opted out of Medicare? There is a difference. Non-par providers must still submit claims to Medicare, they will then pay the patient directly. If a provider is non-par he can decide on a case by case basis if he will accept assignment for ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published November 15th, 2017
Even if a dental provider is not participating in Medicare but still wants to treat Medicare patients, unless the provider actually opts out, they are still restricted to a limiting charge in most states. This means you cannot balance bill a Medicare Beneficiary anything more than 115 percent of the Medicare non-par ...
Dentists Participating in Dental Networks Providing Supplemental Benefits for Medicare Advantage Plans Required to Register with CMS in 2019
October 16th, 2017
By Christine Taxin | Published October 16th, 2017
NADP asked Avalere to estimate the increase in Medicare program costs under current regulation under three participation scenarios: 1) high impact, where the majority of dentists stop participating in MA; 2) medium impact, where the one-third of dentists that currently participate continue to participate; and 3) low impact, ...
By Christine Taxin | Published September 11th, 2017
What has been your definition so far when asked about how they are different? What does an ICD-10 code look like? How does an ICD-10 code work?
Have you seen commercials about medical coding schools and wonder if the profession is right for you? With the field expected to grow faster ...
More than any other industry, healthcare is almost notorious for its lack of price transparency. While patients generally know how much their copay will be and certainly how much their final bill turns out to be, few hospitals and practices publish the actual costs of their services prior to those ...
Do Other States Lower Payments for Crowns by Delta or Blue Cross?
August 11th, 2017
By Christine Taxin | Published August 11th, 2017
Question: A subscribers from the State of Michigan has asked this:
Has anyone from other states seen the fees for crowns lowered by Delta or Blue Cross?
Answer: First look at your contracts, and see if there is anything in it that allows for fees to be lowered. Next, look up your ...
One of the easiest things a practice can do to increase collections makes it easier for patients to pay by whatever method they have available at the time of the visit, says Christine Taxin Adjunct Professor at NYU Dental School and Owner of Links2Success.biz.
Compliance Program - What are the Requirements to Implement an Effective Program?
August 1st, 2017
By Christine Taxin | Published August 1st, 2017
All sponsors are required to adopt and implement an effective compliance program, which must include measures to prevent, detect, and correct Part C or D program non-compliance as well as FWA.
The compliance program must, at a minimum, include the following core requirements:
1. Written Policies, Procedures, and Standards of Conduct;
2. Compliance Officer, Compliance Committee, ...
Prescribers, including dentists, who write prescriptions for Part D drugs are to be enrolled in an approved status or validly opted out with Medicare, in order for their patients’ prescriptions to be covered under Medicare Part D.
Full enforcement of Part D prescriber enrollment requirement will begin on January 1, 2019. ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published April 21st, 2017 - Last Review/Update July 28th, 2017
All radiology services require proper orders, identifying the diagnosis for which the imaging is being ordered. “Rule out” or “Possible” won’t work for reimbursement purposes because professional services cannot code unconfirmed diagnoses. As such, for those types of services, include the symptom(s) as the diagnosis for which you are seeking ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published April 4th, 2017 - Last Review/Update July 28th, 2017
Temporomandibular Joint (TMJ) Syndrome can include a wide variety of conditions that may be characterized as TMJ. Also there are a wide variety of methods for treating these conditions. Many of the procedures are excluded from coverage in the Medicare program for services or devices.
There are other services and appliances ...
Moderate Sedation Services - CPT has 6 Codes to One Dental Code
March 30th, 2017
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published March 30th, 2017 - Last Review/Update August 1st, 2017
When billing a medical code instead of the dental code D9223 -Deep sedation/general anesthesia - each 15 minute increment, consider the following medical codes: (Be sure to review the AMA guidelines to see if they fit the procedure you are doing). If a dental office is doing conscious sedation for a patient ...
Respiratory Assist Devices (RAD) E0470 and E0471 - Billing Reminders
March 28th, 2017
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published March 28th, 2017 - Last Review/Update July 28th, 2017
Add the KX modifier to all claims for RADs and accessories for the first through third months if all thecoverage criteria have been met.
Add the KX modifier to all claims for the fourth month and thereafter if all the coverage criteria have been met and if the physician signed and dated a ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published March 27th, 2017 - Last Review/Update July 28th, 2017
Dynamic splinting systems or devices are used to assist in restoring physical function and are commonly used for treating TMJ. Injury or joint stiffness are diagnoses that may qualify for medically necessity.
If physical therapy has proven ineffective to restore or improve range of motion, mechanical devices are often a next step.
This ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published March 13th, 2017 - Last Review/Update July 28th, 2017
Taxonomy Codes are used to define a Healthcare Provider type as well as the classification and area of specialization. These codes are reported on the ADA form and on the CMS-1500 Medical claim form. For a complete list of all classifications, visit FindACode.com
122300000X - DentistStatus: ActiveDefinition: A dentist is a person qualified by a ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published March 13th, 2017 - Last Review/Update July 28th, 2017
Some procedures are unilateral such as D7840-Condylectomy. It is important to consult with your payer on reporting requirements. Some payers require two separate line items with a LT or RT HCPCS Modifier, while others require only one modifier to be appended to the claim.
When billing a medical code for a Condylectomy, ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 1st, 2017
Don’t let managed dental plans sneak up on you!
Announcing InstaCode's 2017 Reimbursement Guide for Dental with Medical crosswalks.
We are excited to introduce a truly unique product that will be even more beneficial to the financial health of your practice.
Some of the new features include:
CDT, CPT, ICD-10-CM and HCPCS
CDT to CPT ...
Billing for Prosthesis Designed and Prepared by the Dentist
December 6th, 2016
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 6th, 2016 - Last Review/Update August 2nd, 2017
For maxillofacial services, if a prosthesis is provided, and is designed and prepared by the dentist, the Medicare Part B carrier may be billed with CPT codes 21076 through 21089. If the prosthesis is prepared by an outside laboratory, the laboratory bill goes to the Durable Medical Equipment Regional Carrier (DMERC), with Level ...
Dental Examination Prior to Kidney Transplantation
December 6th, 2016
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 6th, 2016 - Last Review/Update August 1st, 2017
Despite the "dental services exclusion" in §1862(a)(12) of the Act (see the Medicare Benefit Policy Manual, Chapter 16, "General Exclusions from Coverage," §140), an oral or dental examination performed on an inpatient basis as part of a comprehensive workup prior to renal transplant surgery is a covered service. This is because ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 6th, 2016 - Last Review/Update August 1st, 2017
Implants, which could be considered dental but are being inserted to secure, attach, or support the maxillofacial prosthesis, will be covered when the prosthesis is to be used secondary to maxillofacial surgery or repair of traumatic injury. Use CPT code 21299 to bill the implants with an explanation of the intended use. ...
Shift Your Focus: The New Generation of Dental Billing
October 3rd, 2016
By Christine Taxin | Published October 3rd, 2016
More and more information emerges each day about the connection between certain serious medical conditions and poor oral health. Consider these headlines found in a recent dental journal: “Periodontal disease may have even more of an impact on overall health than previously thought,” and, “Biomarkers in Saliva Help Detect Early-Stage ...
By Christine Taxin | Published September 27th, 2016
Below is a list of changes in Dental Codes for 2017, please do not use these codes until January of 2017. Also, understand how to use and remember document, document why you are using any code.DIAGNOSTIC D0120-D0999REVISIONS:NO CHANGESNEW CODE:D0414 Laboratory Processing of microbial specimen to include culture and sensitivity studies, ...
Dental Offices - Billing Medical Insurance for covered procedures
September 12th, 2016
By Christine Taxin | Published September 12th, 2016
If your dental office isn’t billing medical insurance for certain procedures, you’re missing out on an important way of serving your patients and expanding your practice. Currently, only about 64% of Americans are covered by a dental insurance plan. But the Affordable Care Act requires nearly 100% of Americans to be covered ...
CON Commission votes to deregulate dental CT scanners
July 19th, 2016
By LARRY EMMOTT | Published July 19th, 2016
Dentists have complained for years that the 10-year rule that required a CON to purchase dental CTs only increased dental practice costs and made it more difficult to diagnose and treat patients.
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published July 12th, 2016
Medical Necessity is the key to coverage under a medical plan for a dental procedure, be sure you review what is required medical necessary under each individual policy, and which procedures need pre-certification, below are some reasons a medical policy may cover.
• Exams, radiographs and consultations for medically necessary dental procedures• ...
What are the classification of materials and why does it matter?
June 9th, 2016
By Christine Taxin | Published June 9th, 2016 - Last Review/Update January 30th, 2017
One topic comes up all the time when i speak on coding. How can i charge the patient for the upgraded material used for a crown?
Best case is to understand the materials that can be used and what you are asking the lab to provide. (online at ADA.or/2190.aspx) lists the ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published June 7th, 2016
To help the understanding of what is covered under Dental and what may be covered under Medical, review Regence's coverage criteria:
Coverage under medical or dental benefits is determined by the condition that is being diagnosed and treated, regardless of whether the service is provided by a dentist or a medical doctor.
MEDICAL POLICY CRITERIA
Note: Member contracts for covered services vary. Member contract language takes precedent over medical policy.
I. Dental Services
Services are covered under dental benefits when the condition being diagnosed and treated is contiguous or localized to the teeth and/or gums or when services are intended to restore lost function of the teeth.
Examples of dental services include but are not limited to:
Have you had to send money back to a dental insurance company? You may have received a letter informing you that a patient received benefits but then turned out to be ineligible and now the insurance company wants their money back. Hopefully, you sent them a check for the amount ...
Policy provision for reimbursement of dental services
May 25th, 2016
By Christine Taxin | Published May 25th, 2016
The law is as follows
“policy provision for reimbursement of dental services: payment regardless of discipline of provider: notwithstanding any provisions of a policy or contract of group health insurance hereafter delivered, issued for delivery, amended, renewed, or ratified whenever such a policy or contract providers for reimbursement for a service which within the lawful scope of practice of a duly licensed dentist, the following provisions shall apply:
May be a Payable Code for Dental Procedures under Medical Policy
May 25th, 2016
By Christine Taxin | Published May 25th, 2016
The following list may be payable Codes for Dental Procedures under a patients Medical Policy. Be sure to verify with the payer for benefit coverage and exclusions.
ICD-10-CM Diagnosis Codes
B00.2 Herpesviral gingivostomatitis and pharyngotonsilitis
K00.0 Andontia
K00.1 Supernumerary Tooth
K00.2 Abnormalites of size and form of tooth
K00.3 Mottled Teeth
K00.4 Disturbances in tooth formation
K00.5 Hereditary ...
By Christine Taxin | Published September 25th, 2015
Coordination of benefits, (COB) is a clause in most group policies, which is in place to minimize the over-payment or duplicate payment of claims. COB applies to patients covered by more than one insurance plan and limits the amount paid by each plan.
With the COB clause the payments made by ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published September 25th, 2015
If you order or refer items or services for Medicare beneficiaries and you do not have a Medicare enrollment record, you need to submit an enrollment application to Medicare. You can do this using the Internet-based Provider Enrollment, Chain, and Ownership System (PECOS) or by completing the paper enrollment application ...
Dental practices that do not work with medical are truly confused when it comes to Medicare. I decided to put together a simple outline of what we should be doing to be compliant with Medicare.
Dental and Medical Providers Work Together in Treating Patients
August 19th, 2015
By Christine Taxin- Links2Success | Published August 19th, 2015
More and more information is coming to light about the role of the mouth as it relates to systemic disease. While research is still unfolding, studies are showing that oral disease can both contribute to and, or be a sign of systemic disease. There has been a call to action ...
A Dental Guide to Cross-Coding for Oral Cancer Screening
August 19th, 2015
By Christine Taxin Adjunct Professor, University of New York School of Dentistry - Links2Success.biz | Published August 19th, 2015
Dental professionals are a patient’s primary source of screening within the oral cavity; thus attention must be paid to the most common oral malignancy: squamous cell carcinoma. Historically such malignancies were attributed only to patients with a history of extensive alcohol and tobacco use. However, other risk factors such as ...
Attention Dentists: How does the switch to new diagnostic codes this year affect you?
August 19th, 2015
By By Greg Alterton, CDA Dental Benefit Plan Specialist | Published August 19th, 2015
Increasingly, dental plans are deferring to medical benefit carriers on certain dental procedures that can be claimed as medical procedures with patients’ medical plans. More and more, these medical plans are paying for not only surgical dental procedures, but some preventive dental services as well.
In submitting claims to medical plans, ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 10th, 2015
Changes are on the horizon for Dentists new diagnosis codes will be changing October 1, 2015. Payers are changing to ICD-10 which will make a great impact on the dental community mainly oral surgeons, dentists who treat temporomandibular disorders, sleep apnea , oral pathologists, facial pain, oral radiologists, pediatric specialists who treat ...
Orthognathic Surgery - Medical Policy Criteria - Regence
August 10th, 2015
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 10th, 2015
Orthognathic surgery involves the surgical manipulation of the facial skeleton, particularly the maxilla and mandible, to restore the proper anatomic and functional relationship in patients with dentofacial skeletal anomalies, which may be caused by congenital or developmental anomalies or by traumatic injury.
[1] Note: This policy does not address the surgical ...
Dental wellness centers: Responding to the oral-systemic treatment gap
August 10th, 2015
By Christine Taxin | Published August 10th, 2015
Dental wellness centers: Responding to the oral-systemic treatment gap
Christine Taxin
Adjunct Professor, New York College of Dentistry
CEO Links2Success.biz
The changing landscape of dentistry
The modern dental landscape has changed. The new models of practice are being guided
by research revealing the link between oral and systemic health. Studies show that up to
50% of heart attacks ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 7th, 2015 - Last Review/Update August 7th, 2017
Notes: Most Aetna HMO plans exclude coverage for treatment of temporomandibular disorders (TMD) and temporomandibular joint (TMJ) dysfunction
For plans that cover treatment of TMD and TMJ dysfunction, requests for TMJ surgery require review by Aetna's Oral and Maxillofacial Surgery patient management unit. Reviews must include submission of a problem-specific history ...
Dentists: Prescriptions and Referring to other providers with Medicare
July 13th, 2015
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published July 13th, 2015
Are you aware you must be participating with Medicare Part D to be eligible to prescribe medication's to patients that have Medicare? If you are not participating, your patients will not be able to fill their prescriptions.
You may also enroll to become an ordering and referring Medicare provider. You will not be recognized ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published July 8th, 2015
SOAP notes (subjective, objective, assessment, plan)
Each letter in “SOAP” is a specific heading in the notes:
SOAP is an acronym for “subjective” ( S ) or the patient’s re-response and feeling to treatment, “objective” (O) or the observations of the clinician, “assessment” (A) or diagnosis of the problem, and “procedures accomplished ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published July 7th, 2015 - Last Review/Update August 7th, 2017
Question: When going through radiology codes for TMJ, I saw different codes for imaging studies of the TMJ. Can you please tell me the difference between 70328, 70330 and 70332?
Michigan Subscriber
Answer: If the documentation indicates a TMJ x-ray in two projections of one side, one film with the mouth open, and one with the mouth ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published July 7th, 2015
ICD-10 will require more specificity in your documentation requirements. It is important to train your staff along with Dentists. Take a look at the specific areas that will be required documentation for Dental:
Type of condition
Onset - acute or chronic
Etiology (cause)
Anatomical location and laterality if laterality applies
Severity - mild, moderate or severe
Stages ...
Dental and Oral Surgical Procedures - UNITEDHEALTHCARE Coverage
June 19th, 2015
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published June 19th, 2015 - Last Review/Update August 8th, 2017
The following is found in Oxfords Dental policy.
Oxford's Dental Department will review requests for dental services rendered:
for the following services when delivered in conjunction with dental services:
Dental services
Oral surgical services
Anesthesia services delivered in conjunction with dental services.
by practitioners of the following specialties: oral/maxillofacial surgery
pediatric dentistry
endodontics
orthodontices
NOTE: All other specialties require Medical Director ...
By Christine Taxin | Published October 20th, 2014 - Last Review/Update January 27th, 2017
Are PPOs are affecting the value of your practice?
Did you know that taking a 20% PPO write-off on a $200 procedure with a 60% overhead cuts practice profits in half?
By participating in PPO plans, you agree to take a certain discount on fees; however, your fixed overhead costs remain the same ...
By Christine Taxin | Published October 20th, 2014 - Last Review/Update January 27th, 2017
Least Expensive Alternative Treatment Clause
What your patients do not know!
When alternate benefit or LEAT provisions are applied, they are not meant to dictate treatment, question professional judgment or interfere with doctor-patient relationships. The ultimate decision on treatment is up to the dentist and patient. The LEAT provision actually funds a ...
By Christine Taxin | Published October 9th, 2014 - Last Review/Update January 27th, 2017
Who has dental benefits?
At year-end 2012, approximately 187 million Americans (2013 NADP/DDPA Joint Dental Benefits Report on Enrollment), or 60 percent of the population, had dental benefits. About 99 percent of dental benefits are provided through an employer or other group programs like AARP. Group coverage also includes public programs like Medicaid, the federal ...
To Participate or Not to Participate, That is The Question.
October 9th, 2014
By Christine Taxin | Published October 9th, 2014 - Last Review/Update January 27th, 2017
Insurance! Can it be profitable or a big loser?
Participating with insurance can initially bring down your revenue as you cut your fees per procedure. It is important to remember that your overhead will not decrease along with the fees. The question is can you make up the revenue by increasing ...
"The Dental Office" CDT Codes, Crosswalking to CPT, and Dental Auditing
January 14th, 2019
Join Aimee Wilcox in an informative webinar on procedural coding for the dental office, how CDT codes crosswalk to CPT codes for medical billing, and auditing concerns to watch for.
August 25, 2014 - "Medicaid Compliance and Your Dental Practice" Fact Sheet - The "Medicaid Compliance and Your Dental Practice" Fact Sheet (ICN 908668) was released and is now available in downloadable format. This fact sheet is designed to provide education on internal compliance programs for dental practices that submit Medicaid claims. It includes information on the value and core elements of a compliance program, steps to establish a compliance program, and other resources.
Dentistry Resources
Reimbursement Guide:
"CPT to CDT" and "CDTÂ to CPT" code crosswalks
"InstaGuide for medical billing
ICD-10-CM Dentistry Cheat Sheet
Provider Documentation Guides
ICD-10-CM Comprehensive Code Books
and more...
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