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Leena
#1 Posted : Friday, July 22, 2022 3:50:18 PM(UTC)
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Good afternoon,

I suffered a traumatic accident while in Spain in November 2011 and had to have several dental procedures to repair my fractured and avulsed teeth (fractured teeth #8 and #10 and #9 avulsed). I went to the ER in Spain and saw a dentist the next day. Upon returning home, I went to an endodontist and dentist to continue repairs. My medical insurance has denied my claims for "incorrect procedure codes." Despite all the dental work being medically necessary they won't accept the CDT codes. These are the procedures I have had done so far:

DENTAL OFFICE IN US
D3310 Endodontic therapy- anterior
D2330 x 2 Resin one surface anterior
D3346 retreat previous RCT- anterior (this was a repeated RCT from the one I had done as an emergency while abroad)
D0140 Limited oral evaluation
D0220 Intraoral periapical images
D0150 comprehensive oral evaluation
D0230 x 4 intraoral-periapical each add'l
D02950 x 4 Core buildup, include any pins
D2740 x 4 Crown-porcelain/ceramic substrate

ENDODONTIST OFFICE IN US
D0220 Intraoral periapical images
D0230 Intraoral periapical each add'l
D0270 Bitewing single image
D9310 consultation 2nd opinion
D3310 endodontic therapy anterior
D3331 treatment of root canal obstruct
D3999 unspecified endo procedure
D0364 CT capture limited view < 1 jaw

I have paid $8k out of pocket and am trying to get part of this reimbursed. I already have PTSD from the accident and then having to argue with the insurance company since February has been a nightmare. They have lied about receiving my claims (twice). I need some help please!

courtneydsnow
#2 Posted : Monday, July 25, 2022 9:01:12 AM(UTC)
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courtneydsnow

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Hi Guest!

D0140 - limited oral evaluation - problem focused
D0150 - comprehensive oral evaluation - new or established patient
D9310 - consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician

The three codes above can be crosscoded to a new or established patient evaluation & management (E&M) codes - 99202-99205 (new patients), or 99211-99215 (established patient):

New patients:
99202 – 15-29 mins
99203 – 30-44 mins
99204 – 45-59 mins
99205 – 60-74 mins

Established patients:
99212 – 10-19 mins
99213 – 20-29 mins
99214 – 30-39 mins
99215 – 40-54 mins



D0220 - intraoral - periapical first radiographic image
D0270 - bitewing - single radiographic image
can be cross coded to:
70300 - Radiologic examination, teeth; single view


D0230 - intraoral - periapical each additional radiographic image
Can be cross coded to:
70310 - Radiologic examination, teeth; partial examination, less than full mouth


D0364 - Cone beam CT capture and interpretation with limited field of view - less than one whole jaw
Can be cross coded to:
76380 - Computed tomography, limited or localized follow-up study


D3310 - Endodontic therapy anterior tooth (excluding final restoration)
D2330 - resin-based composite - one surface, anterior
D3346 - retreatment of previous root canal therapy - anterior
D2950 - core buildup, including any pins when required
D2740 - crown - porcelain/ceramic
D3331 - treatment of root canal obstruction; non-surgical access
D3999 - unspecified endodontic procedure, by report

The codes listed above do not have direct crosscodes we are aware of - many insurers these days will process "D" codes when they are medically necessary services, but since your insurer is not taking them, you can try the CPT code below and include a narrative report describing the procedure:
41899 - Unlisted procedure, dentoalveolar structures


You will also need diagnosis (ICD-10) codes to describe the injury to your teeth as well as how the accident happened.
Based on what you described, here are some coding options for the injury (I recommend having your dentists review these for appropriateness of your case):

For the broken/fractured teeth:
S02.5XXD - Fracture of tooth (traumatic), subsequent encounter for fracture with routine healing
S02.5XXG - Fracture of tooth (traumatic), subsequent encounter for fracture with delayed healing
S02.5XXK - Fracture of tooth (traumatic), subsequent encounter for fracture with nonunion

For the avulsed tooth:
S03.2XXD - Dislocation of tooth, subsequent encounter

If there was pain:
G89.11 - Acute pain due to trauma

For for the code to describe the accident itself, if you'd like to provide me with some details about what type of accident it was and how it happened I'm happy to offer you some coding options.

Hope this helps!
Guest
#3 Posted : Tuesday, August 2, 2022 6:51:29 AM(UTC)
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#4 Posted : Wednesday, August 3, 2022 6:41:46 AM(UTC)
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Guest
#5 Posted : Monday, August 29, 2022 9:20:48 AM(UTC)
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Thank you so much, this is so helpful! I fell from a motorized standing scooter face and teeth first into the curb. I’m resubmitting claim forms from each provider this week in hopes of not being denied and ask for a gap exception bc all dental providers are tier 3.
courtneydsnow
#6 Posted : Tuesday, August 30, 2022 4:38:41 PM(UTC)
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Hi Guest!

Ok great, in that case, based on what you described, here is an ICD-10 code for fall from standing electric scooter:

V00.841A - Fall from standing electric scooter, initial encounter

Hope this helps!
Guest
#7 Posted : Saturday, September 17, 2022 9:11:40 AM(UTC)
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Hi,

Again, thank you so much for your time and all of this useful information. It has made filling out the CMS claim form a lot easier. My insurance company keeps denying procedure code 41899 saying it is not a covered benefit under my plan. I've asked for gap exceptions in all of my claims because there is no MD (or tier 1 or 2) that could have performed any of these treatments. Any suggestions or ways to get around any of these?

Thanks,
Leena
courtneydsnow
#8 Posted : Thursday, September 22, 2022 8:05:23 AM(UTC)
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courtneydsnow

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Hi Guest!

That is interesting your medical plan would say 41899 is not a covered benefit, as it can stand for many different procedures that don't have a specific CPT code assigned to them! If the diagnosis code(s) present on the claim are considered medically necessary, they should consider them, especially in the case of accidental injury. I would suggest to reach out to a patient care advocate and explain the situation to see how they can help guide you.
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