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bshunnarah
#1 Posted : Monday, September 26, 2016 9:59:07 AM(UTC)
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bshunnarah

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Is the cone beam CT SCAN covered on medical for Cancer screening, TMJ, sleep apnea?
If so what is the correct CPT code/dx code
courtneydsnow
#2 Posted : Monday, September 26, 2016 10:44:25 AM(UTC)
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Hi bshunnarah!

Great questions. Most of the medical policies we review list CT's as only medically necessary for pre-surgical for TMD, as usually listed as not medically necessary for sleep apnea.

There is actually not currently a specific CPT code for CBCT……the closest CPT code is: 70486 - Computed tomography, maxillofacial area; without contrast material. Many offices have been using this for some time for CBCT, however, some medical insurers are auditing that code when used for CBCT because the description does not specify “cone beam”.

So, “76497 - Unlisted computed tomography procedure (eg, diagnostic, interventional)” is a good CPT code to use, or, many medical insurers will process the “D” codes for procedures when there is not a specific CPT code available.

For example, here are the “D” codes from HealthPartner’s medical policy for “Cone-beam computed tomography (CT) scan for medically-related dental services”

D0363 - Cone-Beam 3D multi image reconstruction
D0364 - Cone beam CT capture and interpretation with limited field of view - less than one whole jaw
D0365 - Cone beam CT capture and interpretation with field of view of one full dental arc - mandible
D0366 - Cone beam CT capture and interpretation with field of view of one full dental arch
- maxilla, with or without cranium
D0367 - Cone beam CT capture with interpretation with field of view of both jaws, with or without cranium
D0368 - Cone beam CT capture and interpretation for TMJ series including two or more exposures
D0380 - Cone beam CT image capture with limited field of view - less than one whole jaw
D0381 - Cone beam CT image capture with field of view of one full dental arch - mandible
D0382 - Cone beam CT image capture with field of view of one full dental arch - maxilla, with or without cranium
D0383 - Cone beam CT image capture with field of view of both jaws, with or without cranium
D0384 - Cone beam CT image capture for TMJ series including two or more exposures

Here is a link to the full policy:
https://www.healthpartners.com/public/coverage-criteria/cone-beam-scan.htm
Guest
#3 Posted : Wednesday, October 11, 2017 8:47:47 AM(UTC)
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Are there any requirements prior to billing for CBCT's?
courtneydsnow
#4 Posted : Thursday, October 12, 2017 10:24:13 AM(UTC)
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Hi Guest!

Many medical insurers do require that CBCT's are pre-authorized in order to be eligible for reimbursement.
Guest
#5 Posted : Tuesday, January 30, 2018 3:53:28 PM(UTC)
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Will the medical insurance consider payment for the CBCT if it was done without pre-authorization ?

Edited by user Tuesday, January 30, 2018 3:55:33 PM(UTC)  | Reason: Not specified

courtneydsnow
#6 Posted : Tuesday, January 30, 2018 5:05:28 PM(UTC)
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Hi Guest!

Great question. Yes that is certainly possible! Many insurers will require a pre-auth for CBCT, but not all.
Guest
#7 Posted : Wednesday, March 21, 2018 11:39:34 AM(UTC)
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i know this post is a year old, but i came this across when i enter d0364. i did a root canal and this code was not covered thru delta dental. so the dentist is now charging me. I ask before if the root canal procedure is covered, they said yes. I feel this is a bait and switch. charging me 400 additional dollars.
courtneydsnow
#8 Posted : Wednesday, March 21, 2018 3:08:46 PM(UTC)
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Hi Guest!

Do you know the reason delta dental denied it? (i.e. perhaps you could try to bill to your medical insurance first, and then try dental dental again if medical does not cover it with a copy of the EOB from medical)

Also - is your dentist in-network with delta dental? If they are in-network, they should know ahead of time what services are covered and not...
Guest
#9 Posted : Thursday, March 22, 2018 11:23:13 AM(UTC)
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Hi,
I have a similar question..
What does insurance view as an "acceptable" reason for have a cone beam scan? What codes can be used to have a scan pre authorized?
(Besides Implant, Cancer, and TMJ)
courtneydsnow
#10 Posted : Thursday, March 22, 2018 4:28:37 PM(UTC)
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Hi Guest!

Great question. We generally see coverage for CT scans for surgical cases, or at least when surgery is being contemplated. It depends on the insurer, but here is an example of some language from HealthPartner's medical policy titled:"Cone-beam computed tomography (CT) scan for medically-related dental services”


CBCT is covered for the following indications:

-Evaluation of dental implants when coverage criteria under the accidental dental medical coverage policy are met.
-Evaluation prior to one of the following oral surgery indications:
-Removal of maxillo-facial tumor, non-odontogenic cyst (cyst not originating from a tooth or
the closely surrounding tissues), neoplasm or other pathologic entities that, due to their
size and/or anatomic location, appear to encroach, impinge or are invested in/on critical
anatomic structures (e.g. inferior alveolar nerve, maxillary sinus);
-Arthroplasty of Temporomandibular (TM ) fossae or condyle, TM joint replacement;
-Developmental mid-face syndromes such as cleft palate, Treacher-Collins syndrome, etc;
-Surgical reconstruction after severe oral-facial trauma (such as injuries resulting from motor
vehicle accidents, gunshot wounds, boating accidents or other disfiguring trauma). In
addition, when CBCT is requested prior to an oral surgery listed as A-D above, one of the
following must also be satisfied:
-The panoramic radiograph indicates that a deviation from a routine surgical approach is
probable and further data necessary to plan such an approach; OR
-Information obtained by CBCT is considered critical in determining a surgical plan for
the avoidance of disruption, invasion, or fracture of a surrounding, critical oral-facial
structure.
-Evaluation prior to orthognathic surgery (to correct conditions of the jaw) when coverage
criteria under the orthognathic surgery coverage policy are met AND information obtained by
CBCT is considered critical in determining a surgical plan for the avoidance of disruption,
invasion or fracture of a surrounding, critical oral-facial structure.

Indications that are not covered include but may not be limited to:

-CBCT when used in conjunction with non-covered dental procedures including but not limited to dental implants or bone grafting in preparation for dental implants.
-CBCT for other medically-related dental indications not listed above as covered.

Now, as far as the code to use for a pre-auth:
There is actually not currently a specific CPT code for CBCT……the closest CPT code is: 70486 - Computed tomography, maxillofacial area; without contrast material. Many offices have been using this for some time for CBCT, however, some medical insurers are auditing that code when used for CBCT because the description does not specify “cone beam”.

So, “76497 - Unlisted computed tomography procedure (eg, diagnostic, interventional)” is a good CPT code to use, or, many medical insurers will process the “D” codes for procedures when there is not a specific CPT code available.

For example, here are the “D” codes from HealthPartner’s medical policy:

D0363 - Cone-Beam 3D multi image reconstruction
D0364 - Cone beam CT capture and interpretation with limited field of view - less than one whole jaw
D0365 - Cone beam CT capture and interpretation with field of view of one full dental arc - mandible
D0366 - Cone beam CT capture and interpretation with field of view of one full dental arch
- maxilla, with or without cranium
D0367 - Cone beam CT capture with interpretation with field of view of both jaws, with or without cranium
D0368 - Cone beam CT capture and interpretation for TMJ series including two or more exposures
D0380 - Cone beam CT image capture with limited field of view - less than one whole jaw
D0381 - Cone beam CT image capture with field of view of one full dental arch - mandible
D0382 - Cone beam CT image capture with field of view of one full dental arch - maxilla, with or without cranium
D0383 - Cone beam CT image capture with field of view of both jaws, with or without cranium
D0384 - Cone beam CT image capture for TMJ series including two or more exposures

Here is a link to the full policy:
https://www.healthpartne...?contentid=AENTRY_045861

Hope this helps!
Bgonzalez
#11 Posted : Thursday, April 12, 2018 12:42:46 PM(UTC)
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Hi there, i'VE been reading through most of these topics and still have some questions on filing CBCTs scan through Medical.

I understand the best code to use is 70486, however the diagnostic code to go along with it is what I need. We're an orthodontic office and when we take CBCTs we take them on patients who have impacted third molars or impacted cuspids. What would be the best diagnostic codes for that?

Also, most medical insurances do verbal prior authorizations, is that correct?
courtneydsnow
#12 Posted : Thursday, April 12, 2018 4:19:12 PM(UTC)
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Hi Bgonzalez!

70486 may or may not be the best code to use. However, if you do choose to use that code to represent your CBCT's, then here are some diagnosis coding options for impacted teeth:
K01.1 - Impacted teeth
M26.31 - Crowding of fully erupted teeth
R68.84 - Jaw pain
G50.1 - Atypical facial pain
R52 - Pain, unspecified

And correct, many medical insurers do at least allow you to start the pre-authorization request over the phone. You may need to fax in supporting clinical documentation in order for them to approve the authorization request, but not always.

Hope this helps!
Guest
#13 Posted : Wednesday, September 12, 2018 8:34:00 AM(UTC)
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Is it possible to take a CT scan and bill dental for a pano or fmx since you can pull these things from the scan?
courtneydsnow
#14 Posted : Friday, September 14, 2018 4:56:51 PM(UTC)
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courtneydsnow

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Hi Guest!

Great question. Yes you can certainly bill a pano from your CBCT scan. One practice to be weary of would be to bill multiple scans (pano, fmx, ceph, etc etc) instead of the CBCT code, as that could be viewed as unbundling. However, choosing a lesser code is typically not frowned upon.

Hope this helps!
Guest
#15 Posted : Thursday, August 8, 2019 5:14:47 PM(UTC)
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Hello,
I am reading all the CBCT coding tips, super helpful. I worked in general dentistry office and looking for diagnostic codes for implant, extraction, sinus lift related CBCT.
Thanks
courtneydsnow
#16 Posted : Monday, August 12, 2019 10:35:43 AM(UTC)
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courtneydsnow

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Hi Guest!

No problem. The diagnosis code(s) will depend on the patients condition, however here are some common diagnostic codes we see for implant, extraction & sinus lifts:

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
K05.211 - Aggressive periodontitis, localized, slight
K05.212 - Aggressive periodontitis, localized, moderate
K05.213 - Aggressive periodontitis, localized, severe
K05.219 - Aggressive periodontitis, localized, unspecified severity
K05.221 - Aggressive periodontitis, generalized, slight
K05.222 - Aggressive periodontitis, generalized, moderate
K05.223 - Aggressive periodontitis, generalized, severe
K05.229 - Aggressive periodontitis, generalized, unspecified severity
K05.311 - Chronic periodontitis, localized, slight
K05.312 - Chronic periodontitis, localized, moderate
K05.313 - Chronic periodontitis, localized, severe
K05.319 - Chronic periodontitis, localized, unspecified severity
K05.321 - Chronic periodontitis, generalized, slight
K05.322 - Chronic periodontitis, generalized, moderate
K05.323 - Chronic periodontitis, generalized, severe
K05.329 - Chronic periodontitis, generalized, unspecified severity
K05.10 - Chronic gingivitis, plaque induced
K05.11 - Chronic gingivitis, non-plaque induced
K02.3 - Arrested dental caries
K02.51 - Dental caries on pit and fissure surface limited to enamel
K02.52 - Dental caries on pit and fissure surface penetrating into dentin
K02.53 - Dental caries on pit and fissure surface penetrating into pulp
K02.61 - Dental caries on smooth surface limited to enamel
K02.62 - Dental caries on smooth surface penetrating into dentin
K02.63 - Dental caries on smooth surface penetrating into pulp
K02.7 - Dental root caries
K02.9 - Dental caries, unspecified
K03.81 - Cracked tooth
S02.5XXA - Fracture of tooth (traumatic), initial encounter for closed fracture
S02.5XXB - Fracture of tooth (traumatic), initial encounter for open fracture
S03.2XXA - Dislocation of tooth, initial encounter
M26.34 - Vertical displacement of fully erupted tooth or teeth
M26.33 - Horizontal displacement of fully erupted tooth or teeth

Partial loss of teeth, due to periodontal diseases:
o K08.421 - Partial loss of teeth due to periodontal diseases, class I
o K08.422 - Partial loss of teeth due to periodontal diseases, class II
o K08.423 - Partial loss of teeth due to periodontal diseases, class III
o K08.424 - Partial loss of teeth due to periodontal diseases, class IV
o K08.429 - Partial loss of teeth due to periodontal diseases, unspecified class

Partial loss of teeth, due to caries:
o K08.431 - Partial loss of teeth due to caries, class I
o K08.432 - Partial loss of teeth due to caries, class II
o K08.433 - Partial loss of teeth due to caries, class III
o K08.434 - Partial loss of teeth due to caries, class IV
o K08.439 - Partial loss of teeth due to caries, unspecified class

Partial loss of teeth, due to trauma:
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

Partial loss of teeth, due to other specified cause:
K08.491 - Partial loss of teeth due to other specified cause, class I
K08.492 - Partial loss of teeth due to other specified cause, class II
K08.493 - Partial loss of teeth due to other specified cause, class III
K08.494 - Partial loss of teeth due to other specified cause, class IV
K08.499 - Partial loss of teeth due to other specified cause, unspecified class


If these don't fit the bill with your patient's case, feel free to send me along some additional details and we can explore other coding options.

Hope this helps!
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