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#1 Posted : Saturday, April 13, 2019 12:29:44 PM(UTC)

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We have a diabetic patient that had an infection in #3 and the tooth was previously root canal-ed. We extracted and placed bone graft and membrane. Since patient is diabetic we chose to wait to place the implant until we knew she was healing properly. Patient asked us to send all of this to her medical insurance. As I have never billed medical I feel out of my league.

So a few questions

Do I need to wait until the implant is placed to bill to medical? or can I bill now for the extraction and bone graft.

Her insurance gave me the codes we were to use for all of the procedures and said no pre-auth was required and that she had out of network benefits. I was told all of the procedures are covered at 80% after her $500 deductible was met and her out of pocket max is $1200. Does this mean that after she pays $1200 she will not have a copay? I was also told the implant is not broken up into three parts when billing medical. Is this correct?

They said that I would need to provide the diagnostic codes. Would the diabetes be one of those?

Thank you so much for the help! My doctor said if cases like this can be billed to medical with success he wants to send me to a course so that we can offer this to patients. I honestly have about 30 patients now that could benefit from this so i'm hoping this is a success.
#2 Posted : Wednesday, April 17, 2019 9:00:18 AM(UTC)

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Hi Guest!

Great questions:

No you do not need to wait until the implant is placed to medical for the already rendered services - the extraction & bone graft. They each have their own codes! :)

As for the benefit breakdown - yes typically when a patient meets their out of pocket maximum, then coverage kicks in at 100% of the allowed amount of covered services (keep in mind - this is the insurer's allowed amount, not necessarily your fee!)

I am not quite sure what they meant by the implant not being broken up into three parts.....but yes there are CPT codes specifically for implants:
21248 - Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial(3 or less)
21249 - Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); complete (4 or more)

As for the diagnosis codes - this will depend on the reasons why the services are being done.
For example, here are some common codes you may consider based on the situation you described:

K08.21 - Minimal atrophy of the mandible
K08.22 - Moderate atrophy of the mandible
K08.23 - Severe atrophy of the mandible
K08.24 - Minimal atrophy of maxilla
K08.25 - Moderate atrophy of the maxilla
K08.26 - Severe atrophy of the maxilla

K12.2 - Cellulitis and abscess of mouth
K04.6 - Periapical abscess with sinus
K04.7 - Periapical abscess without sinus
K04.1 - Necrosis of pulp
K04.2 - Pulp degeneration
K04.01 - Reversible pulpitis
K04.02 - Irreversible pulpitis

E10.630 - Type 1 diabetes mellitus with periodontal disease
E11.630 - Type 2 diabetes mellitus with periodontal disease
E09.630 - Drug or chemical induced diabetes mellitus with periodontal disease

Hope this helps!
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