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Guest
#1 Posted : Thursday, January 31, 2019 3:11:06 PM(UTC)
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Guest

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Hi- Im looking for a medical procedure code and diagnosis code for a 12 yo diabled boy who fell onto some poorly placed metal bleachers at an indoor sports complex and cracked 2 front teeth in half. His disability required him to have the procedure done at a children's hospital a month after the event where he was placed under general anesthesia.

Dental insurance will not pay for the hospital stay (dental proc code D9420 hosp/surg ctr calls) and it seems like something medical should pay for but they keep kicking it back to dental because of codes-- so need xref and diag code..(im thinking 99221 + K08.411 - Partial loss of teeth due to trauma, class I--???
courtneydsnow
#2 Posted : Friday, February 1, 2019 10:15:01 AM(UTC)
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courtneydsnow

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Hi Guest!

No problem, based on what you described, here are some ICD-10 diagnosis coding options for you:

S02.5XXA - Fracture of tooth (traumatic), initial encounter for closed fracture
S02.5XXB - Fracture of tooth (traumatic), initial encounter for open fracture

It sounds like fractures from your description, but if there were teeth lost:

K08.411 - Partial loss of teeth due to trauma, class I
K08.412 - Partial loss of teeth due to trauma, class II
K08.413 - Partial loss of teeth due to trauma, class III
K08.414 - Partial loss of teeth due to trauma, class IV
K08.419 - Partial loss of teeth due to trauma, unspecified class

(if the class isn't documented/known, choose the unspecified class option)

As for the fall:

W10.8XXA - Fall (on) (from) other stairs and steps, initial encounter
W10.8XXD - Fall (on) (from) other stairs and steps, subsequent encounter
W10.8XXS - Fall (on) (from) other stairs and steps, sequela


As for hospital care CPT codes:
99221 - hospital care, new, level 1
99222 - hospital care, new, level 2
99223 - hospital care, new, level 3
99231 - hospital - subseq., level 1
99232 - hospital - subseq., level 2
99233 - hospital - subseq., level 3


Hope this helps!
Guest
#3 Posted : Monday, May 6, 2019 10:32:39 AM(UTC)
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Hello- I am the OP from a few months ago and need more help... Thanks for the info: the insurance company is kicking back the procedure code 99221 due to it being linked to inpatient care. The procedure was done by an oral surgeon/dentist at a hospital but on outpatient basis-- it required anesthesia which was not available at their office so required the hospital visit...They are ok with the K08.411 - Partial loss of teeth due to trauma, class I as recommended.

Can you tell me the applicable codes for "evaluation for outpatient" or the like?

The thread shown below correctly identifies the issue which was denied using dental codes at first and then converted to 99221 and K08.411 and denied again...I then filed an appeal with the insurance company and they have agreed to pay for it but need the correct "outpatient" code for it to process through their system.

https://dentalwriter.com...t.aspx?g=posts&t=744

Thanks for the help- 7 months waiting and HOURS of work riding on this..

Edited by user Monday, May 6, 2019 3:34:43 PM(UTC)  | Reason: clarification

courtneydsnow
#4 Posted : Tuesday, May 7, 2019 10:40:17 AM(UTC)
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courtneydsnow

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Hi Guest!

Below are the outpatient evaluation & management codes, the first set is for new patients (99201-99205), and the second is for established patients (99211-99215):

99201 - Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.

99202 - Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 20 minutes are spent face-to-face with the patient and/or family

99203 - Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family.

99204 - Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family

99205 - Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family.

Established Patients:

99211 - Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.

99212 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.

99213 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family.

99214 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.

99215 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family


Hope this helps!
Guest
#5 Posted : Tuesday, May 7, 2019 4:02:40 PM(UTC)
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