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oral evaluation

Town & Country Pediatrics & Posted Thu 02nd of May, 2013 18:48:55 PM

Our state's Medicaid program is requiring pediatricians to perform a dental exam at routine physicals and to report it with dental procedure code 'D0145'. We would like to use the same code when billing all of our insurance companies, but at least one payer has been rejecting claims that include this code, since they consider it an invalid code. Is there any simple way around this that will not require us to apply different rules to different payers, while at the same time meet Medicaid's requirements?

SuperCoder Answered Mon 06th of May, 2013 18:44:08 PM


This is a complex situation.My Senior editor is working on this. Please be patient.


SuperCoder Answered Wed 08th of May, 2013 00:27:41 AM

Hi there! There are a few issues at play here. First, you're billing it to Medicaid because Medicaid is requiring it...But when billing a private insurer, you will need medical necessity as a reason for performing a dental exam, and most private payers will not reimburse this for a pediatrician. If they do, they may ask you to include the service in your E/M code, but whether that's possible will depend on exactly what the pediatrician is doing. Is he/she giving a cursory look at the patient's teeth and gums, or is there a more in-depth review of each tooth? A quick review of the teeth and gums, along with advice on proper dental hygiene, can count toward the "ears, nose, mouth, throat" organ system under the E/M guidelines.

Torrey Kim, CPC
Editor, Pediatric Coding Alert

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