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#1 Posted : Wednesday, December 5, 2018 1:50:32 PM(UTC)

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Hello . We billed to medicare for 21248 and 21215 (52). For 21248 we used K08.423. For 21215 we used K08.22. Claim was denied because they considered these ICD codes routine .
what was wrong?

Thank You
#2 Posted : Wednesday, December 5, 2018 6:06:07 PM(UTC)

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Hi Guest!

Great question:

K08.423 stands for:
Partial loss of teeth due to periodontal diseases, class III

K08.22 stands for:
Moderate atrophy of the mandible

For bone grafts and implants, simply loss of teeth due to perio disease and moderate atrophy alone won't always do the trick to establish medical necessity. For example - is the patient experiencing pain or problems with mastication? If there is not something additional like that present, then many medical insurers would deem these procedures cosmetic, or dental in nature. Or for example, many trauma cases would see coverage as medically necessary.

Hope this helps!
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