Uniquely orthodontic medical billing

Editor’s intro: For offices that provide cutting-edge technologies and sleep-related treatment plans, it is important to be aware of new-age billing codes to allow for imaging and appliances that treat this wide array of patients.

Christine Taxin discusses coding for the new age of orthodontics

In the category of billing in the dental field, gone are the days of simple cases and one type of coding. As each practice becomes more of a wellness and total oral healthcare provider, dentists are providing treatment plans for a wide array of patients. Orthodontic care is just one of these specific examples.

In the modern dentist’s office, you will find that 4 out of 5 offices now own a CBCT scanner, which can diagnose and show so many needed details for requesting either traditional or alternative treatments in the orthodontic world. 3D imaging is quickly evolving as the standard of care in orthodontics as new ultra-low-dose CBCT technology offers safer and more affordable volumetric scanning than ever before. The advantages of CBCT over traditional 2D imaging are many, including:

• 3D treatment planning and the transverse dimension
• Airway-centered treatment from information not available using 2D imaging
• Improved pre-existing TMJ knowledge and avoiding “surprises” during treatment
• Mixed dentition and eruption guidance in 3D imaging
• Visual Craniometric Analysis (VCA) — a new paradigm in 3D cephalometrics
• Unparalleled imagery for patient marketing and case acceptance

There are many dental codes for temporomandibular issues and cone beam necessity, but billing to medical will allow the clinician to use additional codes both during the case and at the end of case for documentation and medical necessity.

Examples of these codes include:

• D0382 - 70150 - Cone beam CT for maxilla (TC) Modifier
• D0381 - 70110 - Cone beam CT for mandible (TC) Modifier
• D0383 - 70486 - Cone beam CT for both arches (TC) Modifier
• D0365 - 76376 - Cone beam CT of mandible arch (in office)
• D0366 - 76377 - Cone beam CT of maxilla arch (in office)
• Multiple - See list below - 70486 - Cone beam CT capture and interpretation with limited field of view - less than one whole jaw
• D0380/D0393 - 76380 - Computed tomography, limited or localized follow-up study
• None - 70490 - Computed tomography, soft tissue neck; without contrast material (sleep apnea)
• D0340 - 70350 - 2D cephalometric radiographic image orthodontic
• D0330 - 70355 - Orthopantogram (e.g., panoramic X-ray)

For the code 70486, Cone beam CT capture and interpretation with limited field of view — less than one whole jaw, list the conversion with the following. Use the following for code 70486:

• D0321 - Other temporomandibular joint radiographic images, by report
• D0322 - Tomographic survey
• D0360 - Cone beam CT - craniofacial data capture
• D0362 - Cone beam - two-dimensional image reconstruction using existing data, includes multiple images
• D0364 - Cone beam CT capture and interpretation with limited field of view — less than one whole jaw
• D0365 - Cone beam CT capture and interpretation with field of view of one full dental arch - mandible
• D0366 - Cone beam CT capture and interpretation with field of view of one full dental arch - maxilla, with or without cranium
• D0367 - Cone beam CT capture and interpretation with field of view of both jaws, with and without cranium
• D0368 - Cone beam CT capture and interpretation for TMJ series, including two or more exposures
• D0380 - Cone beam CT image capture with limited field of view — less than one whole jaw
• D0381 - Cone beam CT image capture with field of view of one full dental arch - mandible

In addition to orthodontic care, and while striving to provide complete patient care, another course of treatment many dentists are providing relates directly to sleep apnea. Since the inception of the American Academy of Sleep, an uptick in the number of oral physicians providing sleep apnea care has increased. Many dentists have taken courses and have become providers of durable medical equipment. This means that they are directly involved with medical billing. The good news is that billing for this specific area is quite straightforward, as there is only one diagnostic code for sleep apnea for both adults and children. The code G47.33 must be listed as the diagnosis on the sleep test or it will not receive payment.

• G47.33
  • Obstructive sleep apnea (adult) (pediatric)
  • Obstructive sleep apnea hypopnea

Along with orthodontic care and the monitoring of sleep apnea, dentists need to be mindful of snoring and how appliance placement can possibly aggravate this condition in patients. The American Academy of Craniofacial Pain Task Force on Mandibular Advancement Oral Appliance Therapy for Snoring and Obstructive Sleep Apnea has a specific stance on just how appliances might increase the overall struggle with snoring. The OSA published a position paper in 2013 that states oral appliance therapy has the potential to cause TMD and that orthodontic specialists should be engaged in treatment of both OSA and TMD with expanders that can be watched as the child grows to prevent TMD.¹

There are steps that you can implement to begin the journey of adding the ability to help screen a child for either treatment of sleep apnea or TMD. Of course, you must determine the treatment after the test results are available and collaborate with your patients’ medical provider.

Some patients either do not want to go for a sleep test, or you may want to recommend the use of an expander for the opening of a small airway and still bill to medical as either a sleep appliance for a child or a TMD appliance. When treatment planning for TMD, bear in mind that reversible intraoral appliances (i.e., removable occlusal orthopedic appliance-orthotics, stabilization appliances, occlusal splint, bite appliances/planes/splints, mandibular occlusal repositioning appliances) are or could be used for different reasons, but all are acceptable by insurance. Reversible intraoral appliances may be considered medically necessary in selected cases only when there is evidence of clinically significant masticatory impairment with documented pain and or loss of function. There needs to be a result of 6-8 months of monitoring prior to the application of appliance. The clinician cannot use words such as bruxism (because bruxism is a habit that can be broken so it doesn’t quality) or sports guard (because the sports guard is only worn to protect teeth while playing a sport). Each case must be pre-authorized.

The diagnostic coding for most TMD treatment plans is listed with the insurance policy. You need to check each patient’s policy for the following information:

• Diagnostic X-ray, tomograms, and arthrograms
• Computed tomography (CT) scan or magnetic resonance imaging (MRI) (in general, CT scans and MRIs are reserved for presurgical evaluations)
• Cephalograms (X-rays of jaws and skull)
• Pantograms (X-rays of maxilla and mandible).
  • (Note: Cephalograms and pantograms should be reviewed on an individual basis.)

The following nonsurgical treatments may be considered medical necessary in the treatment of a TMJ disorder:

• Intraoral removable prosthetic devices/appliances, encompassing fabrication, insertion, and adjustment (such as soft and hard stabilization appliances, anterior positioning appliances, anterior bite appliances, and soft resilient appliances)
• Pharmacologic treatment (such as anti-inflammatory, muscle relaxing, and analgesic medications)

The following ICD-10-CM Codes are related to this specific billing:

• Diseases of the digestive system (K00-K95)
  • K00-K14 Diseases of oral cavity and salivary glands
    • K00 Disorders of tooth development and eruption
    • K08 Other disorders of teeth and supporting structures
    • K08.8 Other specified disorders of teeth and supporting structures
• Diseases of the musculoskeletal system and connective tissue (M00-M99)
  • M26 Dentofacial anomalies [including malocclusion]
    • M26.2 Anomalies of dental arch relationship
    • M26.3 Anomalies of tooth position of fully erupted tooth or teeth
    • M26.4 Malocclusion, unspecified
    • M26.8 Other dentofacial anomalies
    • M26.89 Other dentofacial anomalies
• Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)
  • Q65-Q79 Congenital malformations and deformations of the musculoskeletal system
    • Q67 Congenital musculoskeletal deformities of head, face, spine, and chest
    • Q67.0 Congenital facial asymmetry

Cross Codes:

• 21083 - Impression and custom preparation; palatal lift prosthesis
• 41899 - UNLISTED PROCEDURE DENTOALVEOLAR STRUCTURES
• 21110 - Application of interdental fixation device for conditions other than fracture or dislocation, includes removal

All billing requires a Salzman Index to even get a pre-authorization or a sleep study. Next, all information must be completely documented in the form of a narrative template in a S.O.A.P format.

S. Subjective information must be gathered: When the patient is calling to make an appointment, there are several key questions to ask.

• Does the patient take any medications?
• Is the child under the care of a doctor? (all, even a therapist) Document the doctors’names and numbers
• Does the child tend to breathe through his/her mouth?
• Have the child’s parent or teachers noticed:
  • Breathing pauses during sleep
  • Sleepwalking
  • Bedwetting
  • Daytime sleepiness
  • Difficulty concentrating or misbehavior
  • Poor school performance

O. Objective: During your objective part of the visit, you must have a history and physical and /or consultation notes including:

• Address the symptoms reported by guardian
• Symptoms
• Type of sleep study and the reason for ordering the test
• Current treatment plan
• Prior treatment for same issues
• Failed CPAP if ever used
• Copy of sleep test
• Results (Salzman Test) or copy of sleep study with a CPAP intolerance form.

A. Assessment: Reading of all tests taken, Salzman Test, CT scan of the soft tissue of neck area, and the sleep test done with a monitor in an overnight sleep lab.

• Results of apnea/hypopnea index for diagnosis in adults is quite different than for children E0486 - Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment.
• For children: Enlarged tonsils and/ or adenoids are the most common cause of sleep apnea for children having surgery to remove the tissues and often correct the symptoms of sleep apnea.
• List the type of appliance therapy you would use for the treatment showed with the outcome after use of the appliance. Always include the length of treatment.

P: Plan of Action:

• Establishment of medical necessity requires documentation to support the severe handicapping malocclusion and medical condition status.
• To quality for insurance conversation, you must had a score of 42 points on Salzmann index, documentation with a written report from the attending physician, pediatrician and a qualified sleep test.
• All the doctors need to agree or be part of the treatment plan. Many medical providers are asking to have children treated with orthodontic appliance therapy even before the child can have a sleep study.

A final note: When billing some of the common appliances orthodontists make (soft and hard stabilization appliances, anterior positioning appliances, anterior bite appliances, and soft resilient appliances), you may need to use an unlisted code, and in your letter of medical necessity, you must write the entire description the dental code. You also may need to use the dental code on the medical claim since there are dental codes that are not cross coded but are covered with the correct diagnostic reason.²

All codes are owned by the ADA and the AMA and are copywritten by them. I have permission to teach and help providers understand the codes.

Christine Taxin has more guidance for new age billing of OSA and TMJ here.