Here are 3 sample dental claims with diagnoses and codes:
Claim 1:
Diagnosis: Gingivitis
Clinical Findings: Mild inflammation and redness of gums. No bleeding or calculus.
Code: D1110 Prophylaxis - adult
Claim 2:
Diagnosis: Carious lesions on teeth #3 and 14
Clinical Findings: Decay seen on biting surfaces of teeth #3 and 14 upon clinical and radiographic exam.
Code: D2140 Amalgam - one surface, permanent
Claim 3:
Diagnosis: Periodontitis
Clinical Findings: Moderate inflammation, bleeding, 4mm pockets on teeth #19-21, 24-26
finance in dentistry is based on soben peter article said about the varies methods of financing in the world for dentistry and which i included some indian methods in financing as well as kerala.
This presentation provides a comprehensive pro-active review of program development for long-term care patients in the SNF. The course outlines suggestions for how rehabilitation team members can strengthen the Medicare Part B programming in the nursing facility. An overview of the Medicare Part B Guidelines, Part B Caps, Functional Limitation G-Codes, and Manual Reviews is also provided. The presentation also discusses Medicare Part B documentation, goal writing and reasons for denied claims.
1. Gain an understanding of Proactive Medicare Part B Program Development and how to strengthen the program components.
2. Gain a better understanding of Medicare Part B documentation components, goal writing and potential risk for receiving denied claims.
3. Gain an understanding of Medicare Part B Guidelines, Medicare Part B Caps, Functional Limitation G-Codes and Medical Reviews.
As part of the Medicare Physician Fee Schedule Rulemaking, Medicare (CMS) has implemented functional reporting requirements for Medicare Part B Therapy Services provided in a SNF setting. Claims will be returned or rejected without applicable G-Codes and modifiers for dates of services on and after July 1, 2013. These changes increase the risk of inaccurate billing, triggering audit or lost revenue for the therapy services provided.
finance in dentistry is based on soben peter article said about the varies methods of financing in the world for dentistry and which i included some indian methods in financing as well as kerala.
This presentation provides a comprehensive pro-active review of program development for long-term care patients in the SNF. The course outlines suggestions for how rehabilitation team members can strengthen the Medicare Part B programming in the nursing facility. An overview of the Medicare Part B Guidelines, Part B Caps, Functional Limitation G-Codes, and Manual Reviews is also provided. The presentation also discusses Medicare Part B documentation, goal writing and reasons for denied claims.
1. Gain an understanding of Proactive Medicare Part B Program Development and how to strengthen the program components.
2. Gain a better understanding of Medicare Part B documentation components, goal writing and potential risk for receiving denied claims.
3. Gain an understanding of Medicare Part B Guidelines, Medicare Part B Caps, Functional Limitation G-Codes and Medical Reviews.
As part of the Medicare Physician Fee Schedule Rulemaking, Medicare (CMS) has implemented functional reporting requirements for Medicare Part B Therapy Services provided in a SNF setting. Claims will be returned or rejected without applicable G-Codes and modifiers for dates of services on and after July 1, 2013. These changes increase the risk of inaccurate billing, triggering audit or lost revenue for the therapy services provided.
The Art of Practice Management Dental Pearls - October 2016Marianne Harper
An insightful and informative newsletter from the Art of Practice Management. A dental practice management consulting company that focuses on revenue and collection systems, front desk systems and forms, dental insurance processing, medical/dental cross-coding systems and employment-law compliance.
Decosimo's Shannon Farr and Anderson Busby's Amanda Busby co-presented this PowerPoint at the 2012 Tennessee Bar Association's Health Law Primer on October 3, 2012 in Brentwood, TN.
A health insurance roadmap takes a look at some simple solutions to the complex issues facing health insurance, medicare, medicaid, long term care insurance, and the high cost of health expenses in retirement.
This will work because so much of this is already in place and a lot of the rest would be quick and easy to implement. As in all areas, knowledge is power. Consumers can take control of your insurance portfolio by becoming educated about insurance. Better education and understanding will lead to positive results for consumers and for the insurance industry.
The Art of Practice Management Dental Pearls - October 2016Marianne Harper
An insightful and informative newsletter from the Art of Practice Management. A dental practice management consulting company that focuses on revenue and collection systems, front desk systems and forms, dental insurance processing, medical/dental cross-coding systems and employment-law compliance.
Decosimo's Shannon Farr and Anderson Busby's Amanda Busby co-presented this PowerPoint at the 2012 Tennessee Bar Association's Health Law Primer on October 3, 2012 in Brentwood, TN.
A health insurance roadmap takes a look at some simple solutions to the complex issues facing health insurance, medicare, medicaid, long term care insurance, and the high cost of health expenses in retirement.
This will work because so much of this is already in place and a lot of the rest would be quick and easy to implement. As in all areas, knowledge is power. Consumers can take control of your insurance portfolio by becoming educated about insurance. Better education and understanding will lead to positive results for consumers and for the insurance industry.
This challenge presents an opportunity for dental practices to increase their patient base and boost revenue by billing qualifying dental procedures to medical policies instead. Doing so not only helps patients access care to resolve complex oral health issues but also does so cost-effectively while preserving what dental benefits they might have.
This challenge presents an opportunity for dental practices to increase their patient base and boost revenue by billing qualifying dental procedures to medical policies instead. Doing so not only helps patients access care to resolve complex oral health issues but also does so cost-effectively while preserving what dental benefits they might have.
Ensuring your practice has a solid grasp of this coding will minimize denials and delays in payment for the procedures you provide. This article provides a quick overview of important teledentistry coding and billing as well as some best practices for avoiding delayed and denied reimbursement requests.
Ensuring your practice has a solid grasp of this coding will minimize denials and delays in payment for the procedures you provide. This article provides a quick overview of important teledentistry coding and billing as well as some best practices for avoiding delayed and denied reimbursement requests.
Pediatric Dental Benefits Under the ACA - What Employers (and dentists) Need ...Spring Consulting Group
With the ACA requiring health plans to cover pediatric dental plans, a number of questions have arisen from both employers and dentists. Here are a few of the basics that both groups need to know. Please note, that this information is specific to the State of Massachusetts, and some details may change from state to state.
Medical Insurance Concept's By - Prof. Manoj Kumar Pandey, MBA , AIII. Associate Professor - Insurance & Marketing,
Birla Institute of Management Technology (BIMTECH), Greater Noida (NCR).
Thesis and OutlineRasmussen CollegeJordan Townsend1. The.docxssusera34210
Thesis and Outline
Rasmussen College
Jordan Townsend
1. The Issue: Providing affordable, convenient, and high quality of care to patients.
Thesis: The heath care company I have selected for my course project is Metro Dental Care. As a patient at Metro, I personally believe that Metro Dental Care is one of the best dental clinics around, and that’s why I have chosen this company. Metro Dental Care measures their results by recording patient satisfaction. Managing financial reports, and the quality of service they provide to their customers.
I. Introduction
A. Measures the effectiveness
B. Results
C. Use data to implement quality improvement.
II. Body
A. Measure the effectiveness by patient feedback through email, postcards, and patient’s satisfaction surveys that are sent out yearly.
B. Results are measured by performing exams, probing of gums to see the improvement of patient’s dental health.
C. Managers measure the financial data by running financial reports every month to see if they met their forecasted goals.
III. Conclusion
A. Metro Dental Care focuses on making it convenient for their patients and providing affordable dental services for families, children and seniors. Furthermore, measuring the effectiveness of their results by patient feedback through email, postcards, and patient’s satisfaction surveys that are sent out yearly.
Reference:
Metro Dentalcare. (n.d.). Metro-Dental Care. Retrieved 2012, from http://www.metro-dentalcare.com/
?utm_source=google&utm_medium=cpc&utm_campaign=Trademark&utm_adgroup=Trademark&utm_type=%20Broad&utm_
term=metro%20dentalcare
1
Rough Draft
Rough Draft
Rasmussen College
Jordan Townsend
Metro Dental Care is a dental office that provides affordable, convenient, and high quality of care to patients. As a patient at Metro, I personally believe that Metro Dental Care is one of the best dental clinics around, and that’s why I have chosen this company. Metro Dental Care measures their results by recording patient satisfaction.
Managing financial reports, and the quality of service they provide to their customers. Furthermore, the dentists and staff at Metro Dental Care know how important your smile is. Their mission statement states “We pride ourselves in making your smile look great so you not only look good, but feel confident with your smile.”
Metro Dental Care offers convenience for their patients with more than 40 offices throughout the Minneapolis and St. Paul metro area offering flexible hours including early morning, evening and Saturday appointments. Whether you work or live Metro Dental Care has a location near you. Metro Dental Care provides many affordable services for families, children and seniors. Including general dentistry (teeth cleanings, fillings, crowns) and cosmetic dentistry (teeth whitening, veneers, cosmetic crowns). Metro Dental Care also provides dental specialists such as orthodontics (teeth straightening), periodontics (gum di ...
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
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In the DSM-5, all types of substance abuse and dependence have been
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AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
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Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
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As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
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Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
7. Why Am I Here?
Minimize The Impact Of The Patients
Dental Benefit Plan On Your
Practice
Simplify And Streamline The
Reimbursement Process
Educate Customers And Clients To
Enhance Patient Care
22. Congress has looked at the
business tax deduction and
they are losing not only the
revenue from it,
but they also feel there is no
fiscal responsibility on the
fi l ibili h
part of the individual
23.
24. Federal Trade
Commission
Promotes open
competition in the
United States economy
25. Be Advised
The Federal Trade Commission
is strictly enforcing laws against
anti-competitive behavior
anti-competiti e beha ior
through the
g
Department of Justice
Use care and judgment when
adjusting YOUR fee schedule
29. What is motivating the
g
“Patients’ Bill of
Patients’
Rights?”
Rights?”
Is It Need or Greed?
30.
31. National Association of
Dental Plans
“The size of the dental
benefits market can be
reliably estimated at 192
million lives - or 69% of the
US population”
population”
35. Self Funded Plans
The sponsor does not purchase
conventional insurance. Claims
are paid through the services of a
third party administrator with the
direct funds of the employer.
36. Fiduciary
Of,
Of pertaining to, or involving
to
one who holds something ing
trust for another
The keeper and director of
funds
37. Fiduciary Responsibility
The plan administrator (insurance
company) acting in behalf of the plan
purchaser (
h (employer) t pay any and
l ) to d
all claims that are due and payable
based upon the terms of the specific
contract.
38. The Administrator is Paid
4% to 6% of the face value of the
check generated to the dentist.
If the dentist is not paid, the plan
administrator is not paid
p
Procedure codes changed to
payment codes
39. Like Your Bank Insurance
Bank,
Companies and Third Party
Administrators Make Money
By Moving Information For
Their Clients
Very Few Claims Are Paid
With Their Money
41. Usual Fee
The fee that an individual dentist
most frequently charges for a
specific dental procedure
independent of any contractual
agreement.
42. Customary Fee
The fee level determined by the
administrator of a dental benefit plan
from actual submitted f
f t l b itt d fees for a
f
specific dental procedure to establish
the maximum benefits payable under
a given p
g plan for that specific
p
procedure.
43. Reasonable Fee
The fee charged by a dentist for a
specific dental procedure that has
been modified b th nature and
b difi d by the t d
severity of the condition being treated
and by any medical or dental
complication or unusual
p
circumstances.
51. Diagnostic
What is the code number for
fabricating a p
g periodontal chart?
What about the periodontal
evaluation code?
52. Pre-
Pre-Diagnostic Services
New for 2013
D0190 screening of a patient
– A screening, including state and federally
mandated screenings, to determine an
individual’
individual’s need to be seen by a dentist for
diagnosis
53. Pre-
Pre-Diagnostic Services
New for 2013
D0191 assessment of a patient
– A limited clinical inspection that is performed
to identify possible signs of oral or systemic
disease, malformation, or injury, and the
, , j y,
potential need for referral for diagnosis and
treatment
54. Evaluations
The codes in this section have been revised
to recognize the cognitive skills necessary
for patient evaluation The collection and
evaluation.
recording of some data and components
of the dental examination may be
delegated; however, the evaluation,
diagnosis and treatment planning are the
responsibility of the dentist.
55. Evaluations
As with all ADA procedure codes there is no
codes,
distinction made between the evaluations
provided by general practitioners and
specialists. Report additional diagnostic
and/or definitive procedures separately
separately.
56. To Reach A Documented
Conclusion or Diagnosis
g
57. Evaluations
D0120 periodic
D0140 limited
D0145 under 3 years of age
D0150 comprehensive
D0160 d t il d and extensive,
detailed d t i
– by report
D0170 re-evaluation – limited
re-
D0180 comprehensive periodontal
58. Periodic Oral Evaluation
An evaluation performed on a patient of
record to determine any changes in
the patient’s d t l and medical
th patient’ dental d
ti tt’ di l
health status since a previous
comprehensive or periodic evaluation.
59. with CDT-7 was added
CDT-
This includes an oral cancer
evaluation and periodontal
screening where indicated and
indicated,
may require interpretation of
information acquired th
i f ti i d throughh
additional diagnostic p
g procedures.
Report additional diagnostic
procedures separately.
60. Limited Oral Evaluation
An evaluation limited to a specific oral
health problem. This may require
interpretation of information acquired
i t t ti fi f ti i d
through additional diagnostic
procedures.
61. Problem Focused
Typically,
Typically patients receiving this type of
evaluation have been referred for a
specific problem and/or present with
ifi bl d/ t ith
dental emergencies, trauma, acute
infections, etc..
62. Comprehensive Oral
Evaluation
Used by a general dentist and/or a
specialist when evaluating a patient
i li t h l ti ti t
comprehensively. It is a thorough
evaluation and recording of the
e t ao a and t ao a a d and soft
extraoral a d intraoral hard a d so t
tissues.
63. Comprehensive
This includes an evaluation for oral
cancer where indicated, the
evaluation and recording of th
l ti d di f the
patient’s dental and medical history
and a general health assessment.
64. Comprehensive
It may include the evaluation and
recording of dental caries, missing or
unerupted teeth restorations existing
teeth, restorations,
prostheses, occlusal relationships,
periodontal conditions (including
periodontal charting), hard and soft
tissue anomalies, etc
anomalies etc.
65. Detailed and Extensive
A detailed and extensive problem-
problem-
focused evaluation entails extensive
diagnostic and cognitive modalities
di ti d iti d liti
based on the findings of a
comprehensive oral evaluation.
66. Detailed and Extensive
Integration of more extensive
diagnostic modalities to develop a
treatment plan for a specific problem
t t t l f ifi bl
is required. The condition requiring
this type of evaluation should be
described and documented.
67. Problem focused by report
focused,
Examples of conditions requiring this type of
evaluation may include dentofacial
anomalies, complicated perio-prosthetic
anomalies perio-
conditions, complex temporomandibular
dysfunction,
dysfunction facial pain of unknown origin
origin,
severe systemic diseases requiring multi-
multi-
disciplinary consultation etc
consultation, etc..
68. D0170
Re-
Re-evaluation - limited,
problem focused
Established ti t
E t bli h d patient;
not post-operative visit.
p
post- p
Assessing the status of a previously
existing condition.
condition
69. What are the global aspect of
the procedure and condition?
70. Comprehensive
Periodontal Evaluation
New or established patients
showing signs or symptoms of
periodontal disease and for the
patients with risk factors such
as smoking or di b t
ki diabetes.
71. D0180
It includes evaluation of periodontal
conditions, probing and charting,
evaluation and recording of the
patient’s dental and medical
patient’
history and general health
assessment.
t
72. D0180
It may include the evaluation and
recording of dental caries,
missing or unerupted teeth,
restorations,
restorations occlusal
relationships and oral cancer
evaluation.
l ti
73. How Often Can I
Charge For A New
Comprehensive
Evaluation?
How about the new or
established patient?
t bli h d ti t?
74. With CDT-2005
CDT-
The text
“significant change in health
status or other unusual
circumstances, by report”
“three or more years”
is added to the descriptor
76. Professional Visits
D9430 office visit for observation
(during regular scheduled hours)
– no other services performed
D9440 office visit – after regularly
g y
scheduled hours
D9450 case presentation, detailed
presentation
and extensive treatment planning
79. New For 2013
D0391 interpretation of diagnostic image
by a practitioner not associated with the
capture of the image including report
image,
– W now have image capture both with and
We h i t b th ith d
without interpretation
– Complete series no longer includes bitewings
– “radiographic image” replaces “film”
image” film”
80. Radiographic
Frequency?
Complete S i
C l t Series
Two Bitewings
Four Bitewings
Panoramic Film
82. JADA, Vol. 132,
February 2001
“Diagnostic radiographs should be
g g p
used only after clinical
examination,
examination consideration of the
patient’s history and
patient’
consideration of both the dental
and the general health needs of
the patient.”
patient.”
83. ADA Council on Scientific Affairs
“Routine use of “The nature and extent
radiography as part of of the diagnosis
periodic evaluation of required for patient
all patients is an care constitute the
inappropriate only rational basis for
practice”
practice”
ti determining th need,
d t i i the d
type and
frequency ”
frequency…
84. “Radiographs Are Not To
g p
Be Taken Until The Doctors
Hands Or Eyes H
H d O E Have B
Been
In The Patient’s Mouth”
Patient’ Mouth”
Health and Human Services
Public Health Service
Food and Drug Administration
HHS Publication 88-8273
88-
Revised 2004
85.
86.
87. Diagnostic Imaging
D0350 oral/facial photographic
images
– This includes photographic images,
including those obtained by
g y
intraoral and extraoral cameras,
excluding radiographic images
images.
These images should be a part of
the patient’s clinical record.
record
88.
89.
90. New for 2013
Coding Cone Beam
Less than one whole jaw
One full dental arch – mandible
One full dental arch – maxilla
– With or without cranium
TMJ series
With and Without Interpretation
91.
92. Tests and Laboratory
Examinations
D0425 caries susceptibility tests
– not to be used for carious d ti staining
tt b df i dentin t i i
D0460 pulp vitality tests
– Includes multiple teeth and
contralateral comparison(s), as
p ( )
indicated.
D0470 diagnostic casts
93. Miscellaneous Services
D9950 occlusion analysis – mounted
case
– Includes, but is not limited to,
facebow, interocclusal records
tracings, and diagnostic wax-up; for
wax-
diagnostic casts see D0470
casts,
97. Other Surgical Procedures
D7286 biopsy of oral tissue –
soft (all other)
–F surgical removal of
For i l l f
specimen only. This code is not
p y
used at the same time as codes
for apicoectomy / periradicular
curettage.
98. with CDT-2005
CDT 2005
D7288 was the new code
number and the descriptor
was simply changed from
py g
Cytology to Transepithelial
Sample Collection
99. Tests and Examinations
D0431 adjunctive per-diagnostic test that
per-
aids in the detection of mucosal
abnormalities including p
g premalignant and
g
malignant, not to include cytology or
biopsy procedures
This is the code number for most of the
other oral cancer
screening techniques
101. Prophylaxis - Adult
A dental prophylaxis performed on
transitional or permanent dentition
which includes scaling and
polishing procedures to remove
coronal plaque, calculus and
stains.
t i
102. with CDT-2005
CDT-
Descriptor changed to removal
of plaque, calculus and stain
p q ,
from the tooth structure…
As well as local irritational
factors…
factors
103. Some patients may require more
than one appointment or one
extended appointment to
complete a prophylaxis
prophylaxis.
Document need for additional
time or appointments.
ti i t t
105. Doctor
D t Clinical
Cli i l
Diagnosis Findings
Code Narrative /
Attachment
106.
107. •No attachment loss
No
•No bone loss
•Abundance of plaque,
calculus and stain
“Last f i
“L t professionall
D1110 Prophylaxis cleaning was 24
months ago”
ago
108. Don’t bill the benefit
Don’
plan until the prophy is
complete
“S
Some patients may require more than
ti t i th
one appointment or one extended
appointment to complete a prophylaxis.
i t tt l t h l i
Document need for additional time or
appointments.”
appointments.”
i t t
Charge the patient a reasonable fee
109. Fluoride Treatment
Prescription strength fluoride
p
product designed solely for
g y
use in the dental office,
delivered to the dentition under
the direct supervision of a
p
dental professional
111. D1120
Prophylaxis - Child
Refers to a (routine) dental
( )
prophylaxis performed on
primary or t
i transitional
iti l
dentition only.
y
112. If The Dental
Assistant Does The
Coronal Polishing,
g,
What Code Number
Do We Use?
Is it a prophy?
113. O
Other Preventive S
Services
D1330 oral hygiene
instructions
–This may include instructions for
home care. Examples include
tooth brushing technique,
flossing, use of special oral
hygiene aids.
h i id
115. Other Preventive Services
D1351 sealant - per tooth
– Mechanically and/or chemically
prepared enamel surface sealed to
p
prevent decay.
y
116. with CDT-4 was added
CDT-
D2391 resin-based composite
resin-
-one surface posterior
p
Used to restore a carious lesion in
the d ti
th dentin or a ddeeply eroded
l d d
area into the dentin. Not a
preventive procedure.
117. Sealant – per tooth
“Mechanically and/or chemically
prepared enamel surface sealed
to prevent decay”
decay”
These are not preventive resin
p
restorations
118. D1352
preventive resin restoration in a
moderate to high caries risk
patient – permanent tooth
Conservative restoration of an active
cavitated l i i a pit or fi
i d lesion in i fissure that d
h does
not extend into dentin; included placement
of sealant in any radiating non-carious
f l i di i non- i
fissure or pit
120. with CDT-4 was added
CDT-
“Local anesthesia is considered to
be part of restorative procedure”
121. since CDT-2005
CDT-
Descriptor reads
“Local anesthesia is usually
Local
considered to be part of the
restorative procedure”
122. What about Anesthesia?
D9210 local not in conjunction with
j
operative or surgical procedure
D9211 regional bl k
i l block
D9212 trigeminal division block
D9215 local in conjunction with
j
operative or surgical procedure
124. Amalgam Restorations
Tooth preparation all adhesives
preparation,
(including amalgam bonding agents),
liners and b
li d bases are i l d d as part
included t
of the restoration. If pins are used,
they should be reported separately
(
(see 02951) )
125. Primary or Permanent
Amalgam
D2140 one surface
D2150 two surfaces
D2160 three surfaces
D2161 four or more surfaces
f f
126.
127. Identification of Surfaces
Mesial toward the middle
Distal away from the middle
Lingual
Li l facing the tongue
f i th t
Buccal facing the cheek
Occlusal chewing surface of posterior
Incisal cutting surface of anterior
128. Resin Based Restorations
Resin f
R i refers t a broad category
to b d t
of materials including but not
g
limited to composites. May
include bonded composite
composite,
light-
light-cured composite, etc..
129. Resin Restorations
Tooth preparation light-curing, acid-etching
preparation, light-curing acid-etching,
and adhesives (including resin bonding
agents) are included as part of the
restoration. Glass ionomers, when used as
restorations,
restorations should be reported with these
codes.
If pins are used report separately
used,
130. New Generation
Restorative Materials
Sinfony®
Targis®
Targis/Vectris/Ribbond®
T i /V t i /Ribb d
Bellglass HP®
Cristobal+®
RESIN RESTORATIONS
132. Porcelain / ceramic refers t
P l i i f to
those non-metal, non-resin
non- non-
inorganic refractory compounds
processed at high temperatures
(600°C / 1112°F and above)
(600° 1112°
and pressed, polished or milled
– including porcelains, glasses
and glass – ceramics
ceramics.
133. New in 2013
e 0 3
Porcelain / Ceramic
Refers to pressed, fired, polished or milled
materials containing “predominantly”
predominantly”
inorganic refractory compounds including
g y p g
porcelains, glasses, ceramics and glass
ceramics
134. Resin refers to any resin –
based composite, including
p , g
fiber or ceramic reinforced
polymer compound
136. Inlay / Onlay
Metallic
D2510 inlay - one surface
D2520 inlay - two surfaces
D2530 inlay three or more surfaces
i l - th f
D2542 onlay - two surfaces
D2543 onlay - three surfaces
D2544 onlay - four or more surfaces
137. Inlay / Onlay
Porcelain - Ceramic
D2610 inlay - one surface
D2620 inlay - two surfaces
D2630 inlay three or more surfaces
i l - th f
D2642 onlay - two surfaces
D2643 onlay - three surfaces
D2644 onlay - four or more surfaces
138. Inlay / Onlay
Resin-
Resin-Based Composite
D2650 inlay - one surface
D2651 inlay - two surfaces
D2652 inlay three or more surfaces
i l - th f
D2662 onlay - two surfaces
D2663 onlay - three surfaces
D2664 onlay - four or more surfaces
145. What was a sedative filling?
D2940 sedative filling
– Temporary restoration intended to
relieve pain.
– Not to be used as a base or liner
under a restoration
146. New in 2013
D2940 protective restoration
Direct placement of a temporary restorative
material to protect tooth and/or tissue
form. This procedure may be used to
relieve pain, promote healing, or prevent
further deterioration. Not to be used for
endodontic access closure, or as a base
or liner under a restoration.
147.
148. Other Restorative Services
D2950 core buildup including any
buildup,
pins
– Refers to building up of anatomical
crown when restorative crown will
be placed, whether or not pins are
used
D2951 pin retention - per tooth, in
addition t restoration
dditi to t ti
149. with CDT-4 was added
CDT-
A material i placed i th t th
t i l is l d in the tooth
preparation for a crown when there
is insufficient t th strength and
i i ffi i t tooth t th d
retention for the crown procedure.
This h ld t be
Thi should not b reported when
t d h
the procedure only involves a filler
to eliminate any undercut, box
form, or concave irregularity in the
preparation.
150. Your Clinical
Documentation Must
Confirm
50% or > loss of coronal tooth
structure and not a full 2-3 mm
2-
collar of sound tooth structure at
the gingival margin
151.
152. Post and Core
D2952 post and core in addition to
crown, indirectly fabricated
– post and core are custom fabricated
as a single unit.
D2954 prefabricated post and core in
addition to crown
– Core is built around a prefabricated
post. This procedure includes the
core material.
153.
154. Additional Posts
D2953 each additional indirectly
fabricated post – same tooth
p
– to be used with 02952
D2957 each additional prefabricated
post – same tooth
– to be used with 02954
155. D2799 provisional crown
Crown utilized as an interim
restoration of at least 6 months
duration during restorative
treatment to allow adequate
time for healing or completion of
ti f h li l ti f
other procedures.
p
156. D2799 provisional crown
This includes but is not limited to
includes, to,
changing vertical dimension,
completing periodontal th
l ti i d t l therapy or
cracked tooth syndrome.
This is not to be used for a temporary
crown for a routine prosthetic
restoration.
157. Now in 2013
D2799 provisional crown
– Future treatment or completion of diagnosis
necessary prior to final impression Not to be
impression.
used as a temporary crown for a routine
prosthetic restoration
158. Other Restorative Services
D2970 temporary crown (fractured tooth)
– Usually preformed artificial crown, which
is fitted over a damaged tooth as an
immediate protective device. This is not
to be used as temporization during
p g
crown fabrication.
– Deleted w/ CDT-2005 and later
CDT-
resurrected w/ CDT-2007
CDT-
159. New in 2013
D2929 prefabricated porcelain / ceramic
crown – primary tooth
D2990 resin infiltration of incipient
smooth surface lesion
th f l i
– Placement of an infiltrating resin restoration
for t
f strengthening, stabilizing and/or li iti
th i t bili i d/ limiting
the progression of the lesion
160. Redefined with 2013
D2955 post removal (not in conjunction
with endodontic therapy)
D2980 crown repair necessitated by
restorative material failure
D2981 inlay repair
D2982 onlay repair
D2983 veneer repair
161. Other Restorative Services
D2980 crown repair by report
repair,
– Includes removal of crown, if necessary.
Describe procedure
procedure.
D2999 unspecified restorative procedure,
by report
– Use for procedure which is not adequately
described by a code Describe procedure
code. procedure.
162. Plan Provisions
90th Percentile
Alternate Benefit
Coordination of Benefit
Maintenance of Benefit
Non duplication of Benefit
Date of Incurred Liability
Birthday Rule
Predetermination
164. Your office must
follow the benefit
plan provisions
provisions.
Providership is not a
consideration or
excuse.
excuse
165. Even if you are not a
designated plan
provider,
provider you must
still follow the rules
166.
167. Secure Specifics In
Writing From The
g
Plan Or Make Other
Financial
Arrangements.
Arrangements
Get The Benefit Booklet
From The Patient – The
www or Fax Back
168.
169. Always C fi Eli ibilit
Al Confirm Eligibility
With Each Appointment
If you file the claim,
it’s your responsibilit
it’ o r responsibility
170. Eligibility
Benefit Card
Call the day of the patient visit
Reference #
Name of contact
Don’t forget the employer
Don’
Web based plan access
172. What is the 90th
percentile and how is
p
it computed?
p
173. Surcharge
The stated dollar amount paid to the
dentist by the beneficiary, in addition
to th
t other reimbursements received b
i b t i d by
the third-party payer(s)
third-
174. Table of Allowances
A list of covered services with an
assigned dollar amount that
represents the total obligation of the
t th t t l bli ti f th
plan with respect to payment for such
services, but does not necessarily
represent the dentist’s full fee for that
p dentist’
service.
175. Maximum Allowance
The maximum dollar amount a dental
program will pay toward the cost of a
dental
d t l service as specified i th
i ifi d in the
program’s contract provision.
program’
176. Prevailing Fee
Term used by some dental benefit
organizations to refer to the fee most
commonly charged f a d t l
l h d for dental
service in a given area.
Frequently the 51st percentile
177. But what fee goes
on the claim form?
Your full “USUAL” fee
USUAL”
We will talk about
discounts later
178. Alternate Benefit
A provision in a dental plan
contract that allows the third-party
third-
payer to determine the benefits
based on an alternate procedure
that is generally less expensive
then th
th the one provided or
id d
p p
proposed
179. with alternate benefit
The plan is not dictating
treatment, they are only
, y y
determining coverage based
upon that plans specific
contract language
g g
180. Why the plan does
not pay?
Exclusions, limitations
and carve outs of
coverage
181. Coordination of Benefits
A method of integrating benefits
payable under more than one plan
The benefit plans work together
Benefits from all sources do not
exceed 100% of the total charge
182. Maintenance of Benefits
A method of restricting benefits
payable under more than one plan
Secondary plan pays no more than if
it were primary
If primary plan pays, secondary plan
does not
183. Nonduplication of Benefits
A method of restricting benefits
payable under more than one plan
If primary plan pays, secondary plan
does not
If primary plan does not pay,
secondary plan may/may not
184. The Problem
Elimination and/or reduction of
secondary coverage's
y g
although premiums paid by
both primary and secondary
beneficiaries
185. The Solution
Don’t accept authorization for
Don’
payment on secondary coverage
Have the plan reimburse the patient
Financial arrangements based on
primary coverage
186. Rules of Primacy
The plan covering the patient as
anything other than a dependent is
primary
i
The plan without a COB p
p provision is
primary
Lowest dollar threshold is primary
188. Dental benefits are payable
after the effective date of
ft th ff ti d t f
coverage. However
coverage However,
dentures, bridgework and
g
root canals are liabilities:
Dentures-
Dentures-impression is taken
Bridgework-
Bridgework-teeth are prepared
Root Canal-tooth opened by
Canal-
dentist
189. The payer has the
p y
right to ask the
g
p
provider
Prep Date
Impression Date
Seat D t
S t Date
190. With most all benefit
p
plans, services are
not payable or
p y
reimbursable until
they are completed
y p
Make this work in your
favor
191. Assignment of Benefits
A procedure whereby a beneficiary
authorizes the administrator of the
program to forward payment for
covered procedures directly to the
treating dentist.
199. When should you?
When shouldn’t you?
shouldn’
When do you have to??
Why do you have to?
Why should you have to?
Why shouldn’t you have to?
y shouldn’ y
200. simply defined as:
an indication of the dollar
amount to be paid for covered
p
services contingent upon
continuing eligibility
201. First Instance
Important for the patient to know
approximately how much their dental
benefit plan may pay.
Determines full cost of treatment before
treatment is actually started.
202. Second Instance
Since we have no record of having
received a predetermination…
Treatment plan exceeded $250
Benefits are payable for only
diagnostic,
diagnostic preventive and palliative
services
203. Third Instance
Uncooperative patient with no printed
benefit information
“I have insurance and my husband has
insurance. Everything is paid at 100%
in full”
205. Discounts
Total Fee Charged (Question 53) must be
the fee you intend to collect.
It is illegal to discount based on the
p
patients co-payment.
co-p y
Discount must be disclosed when the
claim is filed
filed.
210. Pulp Cap
D3110 direct
– Procedure in which the exposed
pulp is covered with a dressing or
cement that protects the p p and
p pulp
promotes healing and repair.
– Excludes final restoration
211. Pulp Cap
D3120 indirect
– Procedure in which the nearly
exposed pulp is covered with a
p
protective dressing to p
g protect the
pulp from additional injury and to
promote healing and repair via
formation of secondary dentin.
– E l d fi l restoration
Excludes final t ti
212. Pulp Capping procedure
codes are not identifying
cement bases or cavity liners.
They are simply part of the
final restoration
213.
214. D3220 therapeutic pulpotomy
surgical removal of a portion of the pulp
with the aim of maintaining the vitality of
the remaining portion by means of an
adequate dressing
– performed on primary or permanent
teeth
– not first stage of root canal therapy
t fi t t f t l th
– excluding final restoration
215.
216. D3221 pulpectomy
pulpal debridement primary and
debridement,
permanent teeth
– for the relief of acute pain prior to
conventional root canal therapy py
– not to be used by provider
completing endodontic treatment
217. with CDT-4 was added
CDT-
“This procedure is not to be used
when endodontic treatment is
completed on the same day”
218. Endodontic Therapy
Pulpectomy is part of root canal
therapy. Includes all appointments
necessary to complete treatment;
l
also includes intra-operative
intra-
radiographs. Does not include
diagnostic evaluation and
necessary radiographs/diagnostic
images.
images
219. Endodontic Therapy
D3310 anterior
– Excluding final restoration
D3320 bicuspid
– Excluding final restoration
D3330 molar
– Excluding final restoration
220. Endodontic Retreatment
This procedure may include the
removal of a post, pin(s), old root
canal filli material, and th
l filling t i l d the
procedures necessary to prepare the
canals and place the canal filling.
Includes complete root canal therapy.
p therapy.
py
222. Answer the following?
Who did the original root canal?
When was it done?
How and what f il d?
H d h t failed?
– occlusion
– decay
– trauma
How was it retreated?
223. Endodontic Therapy
D3332 incomplete endodontic
therapy; inoperable, unrestorable or
fractured tooth
f t d t th
Considerable time is necessary to
determine diagnosis and/or provide
initial treatment before the fracture
makes the tooth unretainable
224. New in CDT 2011-2012
2011-
D3354 pulpal regeneration –
(completion of regenerative
( p g
treatment in an immature
permanent tooth with a necrotic
pulp); does not include final
restoration
225. D3354 – pulpal regeneration
Includes removal of intra-canal medication
intra-
and procedures necessary to regenerate
continued root development and
necessary radiographs.
This procedure includes placement of a
seal at the coronal portion of the root canal
system.
system
Conventional root canal treatment is not
performed.
f d
226. Apexification /
Recalcification
D3351 initial visit
D3352 interim medication replacement
D3353 final visit
– includes completed root canal therapy
227.
228. Other Endodontic
Procedures
D3999 unspecified endodontic
procedure, by report
procedure
– Used for procedure which is not
p
adequately described by a code.
Describe procedure.
229. Periodontal
How do you sequence the coding
of non-surgical periodontal
non-
treatment for maximum
reimbursement?
230. ICD-
ICD-10 vs.
SNODENT
Systematized
Nomenclature of
Dentistry
231. Annals of Periodontology,
Volume 4, 1999
I.
I Gingival Diseases
II. Chronic Periodontitis
III. Aggressive Periodontitis
IV.
IV Periodontitis as a Manifestation
of Systemic Diseases
232. Annals of Periodontology,
Volume 4, 1999
V.
V Necrotizing P i d t l Di
N ti i Periodontal Diseases
VI. Abscesses of the Periodontium
VII. Periodontitis associated with
Endodontic Lesions
VIII. Development of Acquired
Deformities and Conditions
233. Periodontal Case
Types
What is being treated?
In what anatomic area is
hat
it being treated?
g
234. Gingival Disease
Inflammation of the gingiva
characterized clinically by changes in
color, gingival f
l i i l form, position, surface
iti f
appearance, and presence of
bleeding and or exudate
235. Early Periodontitis
Progression of the gingival
inflammation into deeper periodontal
structures and alveolar b
t t d l l bone crest, t
with slight bone loss. There is usually
a slight loss of connective tissue
attachment and alveolar bone
236. Moderate Periodontitis
A more advanced stage of the above
condition, with increased destruction of the
periodontal structure and noticeable loss
of bone support, possibly accompanied by
an increase in tooth mobility There may
mobility.
be furcation involvement in multi-rooted
multi-
teeth
237. Advanced Periodontitis
Further progression of periodontitis with
major loss of alveolar bone support
usually accompanied b i
ll i d by increased
d
tooth mobility.
Furcation involvement in multi-rooted
multi-
teeth is likely
238. Refractory Periodontitis
Includes those patients with multiple
disease sites which continue to
demonstrate attachment loss after
appropriate therapy. These sites
presumably continue to be infected by
periodontal pathogens no matter how
thorough or frequent the treatment
provided
239. Anatomic Area
Being Treated?
Per Tooth
Per Site
Per Sit Per Quadrant
P Site -P Q d t
Per Quadrant
Per Arch
Per M th
P Mouth
240. Areas of the Oral Cavity
00 entire oral cavity
ti l it
01 maxillary arch
y
02 mandibular arch
10 upper right quadrant
20 upper left quadrant
30 lower left quadrant
40 lower right quadrant
241. Gingivectomy / Gingivoplasty
It is performed to eliminate
suprabony pockets or to restore
normal architecture when gingival
enlargements or asymmetrical or
unaesthetic topography is evident
with normal b
ith l bony configurations
fi ti
242. Surgical Services
D4210 gingivectomy or gingivoplasty
– Four or more contiguous teeth or
bounded teeth spaces per quad
D4211 gingivectomy or gingivoplasty
– One to three teeth per quad
teeth,
243. New for 2013
D4212 gingivectomy or gingivoplasty to
allow access for restorative procedure,
– per tooth
244. Surgical Services
D4230 anatomical crown exposure
– four or more contiguous teeth
– per quadrant
d t
D4231 anatomical crown exposure
– one to three teeth
– per quadrant
245. Surgical Services
D4249 clinical crown lengthening
– hard tissue
With adjacent teeth, the crown
teeth
lengthening of a single tooth will
involve a minimum of th
i l i i f three t th
teeth.
246. Clinical Crown Lengthening
This procedure is employed to allow
restorative procedure or crown with
little
littl or no tooth structure exposed to
t th t t dt
the oral cavity. Crown lengthening
requires reflection of a flap and is
p
performed in a healthy py periodontal
environment...
247. Surgical Services
D4260 osseous surgery
– including flap entry and closure
– four or more bounded teeth spaces per
quadrant
Modifies the bony support of the teeth by
reshaping the alveolar process to achieve
physiologic form. Procedure must include
the removal of supporting bone.
248. Scaling and Root Planing
Involves instrumentation of the crown
and root surfaces of the teeth to
remove plaque and calculus f
l d l l from
these surfaces. It is indicated for
patients with periodontal disease and
is therapeutic, not p p y
p , prophylactic, in
,
nature.
249. Scaling and Root Planing
Root planing is the definitive procedure
designed for the removal of
cementum and dentin that is rough
and/or permeated by calculus or
contaminated with toxins or
microorganisms. It may be used as a
definitive treatment or as part of a
pre-
pre-surgical procedures.
250. Adjunctive Periodontal
Services
D4341 scaling and root planing
– Four or more teeth per quadrant
Some soft tissue removal occurs.
251. What about the
patient who need
only limited scaling
and root planing?
What code number do
we use?
252. Adjunctive Periodontal
Services
D4342 scaling and root planing
– one to three teeth per quadrant
Some soft tissue removal occurs.
253. Non-
Non-Surgical
Periodontal Service
D4355 full mouth debridement
to
t enable comprehensive
bl h i
evaluation and diagnosis
g
254.
255.
256. D4355
The gross removal of plaque
and calculus that interfere with
the ability of the dentist to
perform a comprehensive oral
evaluation.
l i
This preliminary procedure
does not preclude the need for
additional procedures
procedures.
257. D4355
When an evaluation
evaluation,
diagnosis and
radiographs are not
possible.
Not
N t a routine procedure
ti d
259. Adjunctive Periodontal
j
Services
D4381 localized delivery of
y
antimicrobial agents via a
controlled release vehicle into
diseased crevicular tissue,
– per t th
tooth
– by report
y p
260. D4381 redefined
38 ede ed
FDA approved subgingival delivery
devices containing antimicrobial
medications are inserted into the
periodontal pockets to suppress the
pathogenic microbiota. These devices
microbiota
slowly release the pharmacological
agents so they can remain at the
intended site of action in a therapeutic
concentration for a length of time.
t ti f l th f ti
261. Forget about the trade
name of the product
Tell the payer about the
drug,
drug its concentration and
dosage
262. Other Periodontal
Services
D4910 periodontal maintenance
procedures (following active therapy)
This procedure is for p
p patients who have
previously been treated for
periodontal disease
disease.
263. D4910
This procedure is instituted following
periodontal therapy and continues at
varying i t
i intervals, d t
l determined b th
i d by the
clinical evaluation of the dentist, for
the life of the dentition or any implant
replacement.
p
264. D4910 Includes
Removal of the bacterial plaque and
calculus from supragingival and
subgingival regions
b i i l i
Site specific scaling and root p
p g planing
g
where indicated (D4341 or D4342)
and
polishing of the teeth (D1110).
265. Wh t b t th
What about the
evaluation?
Is it charged out
separately?
Can the hygienist do the
evaluation?
266. “Periodic
maintenance
i t
treatment following
t t t f ll i
periodontal therapy is
not synonymous with
a prophylaxis”
prophylaxis”
271. Complete Dentures
D5110 maxillary
D5120 mandibular
D5130 immediate maxillary
D5140 immediate mandibular
D5810 interim maxillary
D5811 interim mandibular
D5860 overdenture – complete, by report
p , y p
272. Partial Dentures
D5211 maxillary resin base
y
D5212 mandibular resin base
D5213 maxillary cast metal w/resin b
ill l / i base
D5214 mandibular cast metal w/ base
D5225 maxillary w/ flexible base
D5226
5 6 mandibular w/ flexible base
a d bu a / e b e
D5861 overdenture – partial, by report
273. Removable Prosthetics
Adjustments to Dentures
Repairs to Dentures
Repairs to Partial Dentures
Denture Rebase Procedures
Denture Reline Procedures
274. New in CDT 2011-2012
2011-
D5993 maintenance and
cleaning of a maxillofacial
g
prosthesis (extra or intraoral)
other than required
adjustments, by report
j , y p
276. D6010
Surgical placement of implant
body: endosteal implant
Includes second stage surgery and
placement of healing cap
277.
278. deleted code D6020
Abutment placement or
substitution: endosteal implant
An abutment is placed to permit
fabrication of a dental prosthesis.
p
This procedure may include the
removal of a temporary healing cap
or replacement with an abutment of
alternate design
design.
279.
280. Implant Abutments
D6056 prefabricated –
– includes modification and
placement
– Modification of a prefabricated
abutment may be necessary
281. Implant Abutments
D6057 custom fabricated
– includes placement
– created by a laboratory process,
specific for an individual application
282. New for 2013
D6051 interim abutment
– Includes placement and removal
– A healing cap is not an interim abutment
D6104 bbone graft at time of implant
ft t ti fi l t
placement
284. New in CDT 2011-2012
2011-
D6254 interim pontic
D6795 interim retainer crown
Used
U d as an i t i restoration f a d ti of
interim t ti for duration f
less than six months when a final impression
is not made to allow adequate time for healing
or completion of definitive treatment planning.
These are not temporary pontics and retainer
p yp
crowns for routine prosthetic fixed partial
denture restoration.
287. Snoring Appliances
D5999 unspecified maxillofacial
prosthesis, by report
physician referral
copy of sleep study showing
confirmed di
fi d diagnosis
i
288. Is it a medical
liability or a
dental
d t l
p
prosthesis?
Let the plans decide so the
patient can pay the bill
290. Extractions
D7111 coronal remnants –
deciduous tooth
– soft tissue retained coronal remnants
D7140 erupted tooth or exposed root
p p
(elevation and/or forceps removal)
– Includes routine removal of tooth
structure, minor smoothing of socket
bone and closure, as necessary
closure
291. Surgical Extractions
Redefined in CDT 2011-2012
2011-
D7210 surgical removal of erupted
tooth requiring removal of bone
and/or sectioning of tooth, and
d/ ti i f t th d
including elevation of mucoperiosteal
flap if indicated
– Includes cutting of g g
g gingiva and bone,,
removal to tooth structure, minor
smoothing of socket bone and closure
g
292. New in CDT 2011-2012
2011-
D7251 coronectomy – intentional
partial tooth removal
Intentional partial tooth removal is
performed when a neurovascular
complication is likely if the entire
impacted tooth is removed
removed.
294. D9110
Palliative (emergency ) treatment of
dental pain - minor procedure
This is typically reported on a “per
visit” basis for emergency treatment
g y
of dental pain
296. Are We Now Ready
To Get The Correct
Information To
The Patients
Insurance Company?
p y
297. Health Insurance Association
of America (AHIP)
Nine out of 10 claims are
processed within 21 days of receipt
p y p
Almost 16% of claims are received
more than 60 days after services
have been provided to the patient
Almost half of all claim
delays/denials (48%) are due to the
submission of duplicate claims
298. Send all of your claims and
attachments electronically
299. Electronic Claims and
Attachments
Practice Management System
Electronic Claims Vendor
www. Based All Payer - Player
Freedom of Choice
Beware the Unethical Billing
Service