|
19.18.6 Comprehensive Orthodontic Treatment
Comprehensive orthodontic services (procedure code D8080) are restricted to clients who are 12 years of age and older or clients who have exfoliated all primary dentition.
National procedure codes do not allow for any work-in-progress or partial billing by separating the three orthodontic components: diagnostic work-up, orthodontic appliance (upper), or orthodontic appliance (lower).
When billing for comprehensive orthodontic treatment, D8080, three local codes must be submitted as remarks codes along with code D8080. Local codes (Z2009, Diagnostic work-up approved, Z2011, Orthodontic appliance, upper, or Z2012, Orthodontic appliance, lower) are placed in the Remarks Code field on electronic claims or Block 35 on paper claims.
Note: If the remarks code and procedure code D8080 are not submitted, the claim will be denied.
Each remarks code pays the correct reimbursement rate which, when combined, totals the maximum payment of $775. D8080 must be billed on three separate details, with the appropriate remarks code, even if billing for the work-up and full banding. Billing only one detail for a total of $775 will not be accepted.
Example 1: A client is approved for full banding, but after the initial work-up, the client discontinues treatment. This provider would bill the national code D8080 and place the local code Z2009, Diagnostic work-up approved, in the Remarks/comment field. The claim would pay $175.
Example 2: A client is approved for full banding. The provider continues treatment and places the maxillary bands. The provider would bill the national procedure code D8080 and place the local code Z2009, Diagnostic work-up approved, and Z2011, Maxillary bands, in the Remarks/comment field. The claim would pay $475.
All electronic claims for D8080 must have the appropriate remarks code associated with the procedure code.
Providers should adhere to the following guidelines for electronic claim submission so that TMHP can accurately apply the correct remarks code to the appropriate claim detail.
A Diagnostic Procedure Code (DPC) remarks code must be submitted, only once, in the first three bytes of the NTE02 at the 2400 loop.
Example 1: For a claim with one detail, submitted with procedure code D8080 and remarks code Z2009, enter the information as follows: DPCZ2009. The total billed would be $175.
Example 2: For a claim with two details, where details one and two are procedure code D8080 and the remarks codes are Z2009 and Z2011, enter the information as follows: DPCZ2009Z2011. The total billed would be $475.
Example 3: For a claim with three details, where all three details are submitted separately with procedure code D8080, enter the remarks code based on the order of the claim detail as follows: DPCZ2009Z2011Z2012. The total billed would be $775.
This method ensures accurate and appropriate payment for services rendered and addresses the need for partial billing.
|
