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Dentist blog from Delta Dental

Tag: CDT codes (Page 1 of 2)

Why your claims with x-rays are being denied and what you can do

Some procedure codes require the submission of documentation with claims for Delta Dental PPO™ and Delta Dental Premier® patients. Let’s review radiographic image requirements for common procedures and the associated denials that can occur.

Crowns

Pre-operative and periapical (depicting the apex) radiographic images are required when submitting crown procedures D2710 through D2794. Do not substitute a panoramic radiograph to replace periapical images. Radiographs must show the endodontic and periodontal state of the tooth and must be taken within one year of the crown prep procedure.

Photographs must accompany radiographs when evidence of necessity is not obvious on the radiographs.

Lab slips should be maintained as part of the patient record.

In this example, the following radiographic images fail to depict the entire tooth. Pre-operative radiographic images must show the apex (tip of the tooth’s root) and are requested to rule out associated periapical pathology.

In comparison, the following radiographic image correctly depicts the apices of the submitted teeth.

Common reasons for crown denials

Core buildup, including any pins

Periapical radiographs taken within one year of the planned treatment are required when submitting core buildup and post and core procedures D2950 through D2957.

Do not substitute a panoramic radiograph to replace periapical images.

A narrative is also required. Per the American Dental Association, build-ups should not be reported when the procedure only involves a filler to eliminate any undercut, box form, or concave irregularity in the preparation.

Common reasons for core buildup denials

  • 570. Benefits could not be determined because of missing pre-operative periapical radiographic images.
  • 5L8. Benefits could not be determined because of missing pre-operative periapical radiographic images.
  • 5RX. Benefits could not be determined, because the submitted radiograph does not depict the entire tooth.
  • 569. Benefits could not be determined because of the non-diagnostic nature of the radiographic images submitted.
  • 564. Submit clinical treatment narrative.
  • 5BU. The fee for buildups is included in the fee for the completed restoration unless there is extensive loss of tooth structure.

Endodontics

Pre-operative and post-operative periapical radiographs are required when submitting endodontic procedures D3310 through D3330 and D3921. All radiographs, including working radiographs, should be maintained in the patient treatment record.

The following radiographic image fails to depict completed root canal therapy on the submitted teeth.

In contrast, the following radiographic images correctly depict an acceptable pre-operative periapical x-ray and post-operative x-ray of completed root canal therapy on the submitted tooth.

In this second example, the following radiographic images correctly depict an acceptable pre-operative periapical x-ray and post-operative x-ray of completed root canal therapy on tooth #19.

If your endodontic claim is denied, you may see one of the following denial codes:

  • 570. Benefits could not be determined because of missing pre-operative periapical radiographic images.
  • 5L8. Benefits could not be determined because of missing pre-operative periapical radiographic images.
  • FMW. Benefits could not be determined because of missing pre- and post-operative periapical images.
  • 8L9. Benefits could not be determined because of missing post-operative radiographic images of completed root canal therapy.
  • 5RX. Benefits could not be determined, because the submitted radiograph does not depict the entire tooth.
  • 569. Benefits could not be determined because of the non-diagnostic nature of the radiographic images submitted.

Periodontics, including scaling and root planning

When submitting periodontic procedures D4210 through D4212, D4240 through D4245, D4260 through D4285, D4341 through D4342 or D4381, you must include bitewing radiographs taken within 12 months of the planned treatment that show both arches of bone levels. Furthermore, loss of alveolar crest height beyond the normal 1-1.5-millimeter distance to the cementoenamel junction (CEJ) must be evident on radiographs. Periapical or panoramic radiographs can only be substituted when bone loss exceeds levels that can be captured in a vertical bitewing.

Other requirements include periodontal charting (probing) completed within the past 12 months, periodontal case type and diagnosis with detailed clinical chart notes regarding the necessity of the periodontal treatment.

The following bitewing x-ray is nondiagnostic, as the interproximal contacts are overlapped and fail to show bone loss. 

Compare this to the following bitewing x-ray, which depicts both appreciable bone loss and calculus. 

Common reasons for periodontic denials

  •  Benefits could not be determined because of missing full-mouth radiographic images. (Note: This code may also be used to request bitewing x-rays.)
  • 5F5. Submit dated pre-operative diagnostic radiographs, current periodontal chart, dated appointment schedule and clinical treatment notes. 
  • 426. Benefits could not be determined because of missing radiographic images, periodontal charting and treatment record.
  • 5GB/5GC. Submit current periodontal chart, dated pre-operative diagnostic radiographs and a copy of the patient treatment record.
  • 574. Benefits could not be determined because of missing periodontal charting.
  • 569. Benefits could not be determined because of the non-diagnostic nature of the radiographic images submitted.
  • 5GJ. Submit dated copy of the original treatment notes.
  • 5F8. Submitted documentation fails to support payment of benefits for scaling and root planing.

Crown lengthening

Pre-treatment bitewing radiographs taken within 12 months of the planned treatment are required when submitting for the crown lengthening procedure (D4249).

A detailed clinical narrative is also required.

When procedure D4249 is performed on the same day as the preparation/placement of the crown, a separate fee for procedure D4249 may not be charged to the patient or Delta Dental. Prior to final restoration of a tooth, a minimum of four weeks must be allowed following clinical crown lengthening.

Common reasons for crown lengthening denials

  • 573. Benefits could not be determined because of missing full-mouth radiographic images.   (Note: This code may also be used to request bitewing x-rays.)
  • 564. Submit clinical treatment narrative.
  • 569. Benefits could not be determined because of the non-diagnostic nature of the radiographic images submitted.
  • 9WA. The fee for this procedure is considered to be part of and included in the fee for a completed service.

Implant supported prosthetics

You are required to include current periapical radiographs, including the apex of the implant body and surrounding bone, when submitting for implant-supported prosthetic procedures D6055 through D6077, D6082 through D6088, D6094, D6097 through D6099, D6110 through D6123 and D6194 through D6195. 

Do not substitute a panoramic radiograph to replace periapical images. Pre-operative x-rays depicting each implant site are required to determine payment of benefits on pre-authorizations. We must receive post-operative x-rays of implant placement to determine payment of benefits on paid claims. These x-rays must depict the entire implant.

Photographs, if available, may also be submitted for review.

For example, the following panoramic radiographic x-ray is nondiagnostic. It fails to clearly depict implant placement at site #9. Do not substitute a panoramic radiograph to replace periapical images.

The following post-operative periapical x-ray, however, correctly depicts the apex of the implant body and surrounding bone.

Common reasons for implant-supported prosthetic denials

  • 570. Benefits could not be determined because of missing pre-operative periapical radiographic images.
  • 5L8. Benefits could not be determined because of missing pre-operative periapical radiographic images.
  • 586. Benefits could not be determined because of missing post-operative radiographic images.
  • 5RX. Benefits could not be determined, because the submitted radiograph does not depict the entire tooth.
  • 569. Benefits could not be determined because of the non-diagnostic nature of the radiographic images submitted.

Fixed prosthodontics (bridge abutment crowns)

When submitting for fixed prosthodontic procedures D6710 through D6794, you are required to include pre-operative periapical radiographs that show the current endodontic and periodontal state of the tooth. These x-rays must be taken within one year of the crown prep procedures. Do not substitute a panoramic radiograph to replace periapical images.

Photographs, if available, may also be submitted.

Lab slips should be maintained as part of the patient record.

In this example, the radiographic image is nondiagnostic, as it fails to clearly depict the submitted abutment teeth.

In comparison, the following radiographic images for proposed bridge 13-15 clearly depict abutment teeth #13 and #15.

Common reasons for fixed prosthodontic denials

  • 570. Benefits could not be determined because of missing pre-operative periapical radiographic images.
  • 5L8. Benefits could not be determined because of missing pre-operative periapical radiographic images.
  • 5RX. Benefits could not be determined, because the submitted radiograph does not depict the entire tooth.
  • 569. Benefits could not be determined because of the non-diagnostic nature of the radiographic images submitted.

Oral surgery (impacted tooth)

Current periapical or panoramic radiographs are required when submitting oral surgery procedures D7210 through D7241 and D7251. Radiographs are necessary to evaluate conditions detected by history and clinical examination and are essential to detect, diagnose, and treat conditions that otherwise may be difficult to identify.

Further, as the classification of impactions is based on the anatomical position of the tooth rather than the surgical technique employed in removal, preoperative radiographs should be maintained in the patient treatment record.

Detailed, tooth specific clinical chart notes regarding the necessity of the treatment and photographs, if available, should be submitted.

The following panoramic x-ray clearly depicts the anatomical position of the third molars.

Common reasons for oral surgery denials

  • 570. Benefits could not be determined because of missing pre-operative periapical radiographic images.
  • 5L8. Benefits could not be determined because of missing pre-operative periapical radiographic images.
  • 5T2. Benefits could not be determined because of missing pre-operative panoramic radiographic image.
  • 5RX. Benefits could not be determined, because the submitted radiograph does not depict the entire tooth.
  • 569. Benefits could not be determined because of the non-diagnostic nature of the radiographic images submitted.

General tips for submitting x-rays

To expedite the processing of your claim and to ensure timely benefit determination, always submit the appropriate mounted and dated x-rays and supporting documentation on your initial submission. Enter the required documentation information in the “Remarks” or “Comments” field of the claim.

You can refer tothe Submission Requirements table, which is located on pages 4-1 through 4-3 of the 2022 Claims Processing Policies and Procedures Handbook, to identify the necessary documentation and clinical information required for review of specific procedure codes.Please refer to the specific procedure code in the handbook for more details regarding the description of procedures.

Please do not submit original radiographic images if they are the only diagnostic record for your patient. Duplicate radiographs or radiographic image copies of diagnostic quality, including paper copies of digitized images, are acceptable. We do not return radiographic images or other documentation submitted with paper claims; however, we will make an exception when we receive a stamped, self-addressed envelope with the claim.

During clinical review of claims and pre-treatment estimates, Delta Dental reserves the right to request radiographic images and documentation for procedures that otherwise may be identified as not requiring the submission of documentation.

CDT coding and nomenclature are the copyright and a trademark of the American Dental Association, all rights reserved.

Claim tips: Dental implants

Implants and the procedures associated with them are not covered benefits under most Delta Dental plans. But when implant services are covered, most denials are because of coding errors rather than a lack of coverage.

Let’s take a look at some common reasons for denials for implants and the procedures and prostheses associated with them.

Prefabricated abutment vs. custom fabricated abutment

Prefabricated abutments and custom fabricated abutments use separate codes:

  • D6056: Prefabricated abutment — includes modification and placement
  • D6057: Custom fabricated abutment — includes placement

Prefabricated abutments are machine made and may require modification, while custom fabricated abutments are created by a laboratory process and are specific for an individual application.

Abutment-supported vs. implant-supported crowns

Abutment-supported crowns use a prefabricated abutment (D6056) or a custom fabricated abutment (D6057) to attach a prosthetic crown to the implant body. Abutment-supported single and fixed partial denture crowns require the submission of accompanying abutment codes.

Implant-supported crowns attach directly to the implant body without an abutment. Implant-supported single and fixed partial denture crowns do not require the submission of accompany abutment codes.

The following image contains an example of incorrect coding. In it, the dental office submitted custom fabricated abutments (which are coded D6057) with implant-supported crowns (coded D6065) for teeth #19 and 20. But implant-supported crowns are not attached to the implant with an abutment, so the procedures should have been coded as abutment-supported crowns.

In the following correctly coded image, the dental office submitted custom fabricated abutments (D6057) with abutment-supported crowns (D6058) for teeth #19 and 20 implant supported crowns, which are attached to the implant using an abutment.

If you receive a denial for abutment-supported or implant-supported crowns, it may be one of the following:

  • 161. Benefits could not be determined because of missing/conflicting information
  • 7C2. The submitted procedure is not payable due to the absence or conflict of a related service.
  • 9WA. The fee for this procedure is considered to be part of, and included in the fee for, a completed service.

Single implant crowns vs. fixed partial denture implant crowns

A prosthetic crown that is used to restore one implant is known as a single implant crown. A prosthetic crown that is attached to an implant and is used as a bridge anchor to replace missing teeth is known as a fixed partial denture implant crown.

Here is an example of incorrect coding for these crowns.

ToothCode
#29D6065 (incorrect)
#30D6245
#31D6065 (incorrect)

In this example, the coding is incorrect because the abutments on teeth #29 and 31 are coded as single crowns. For this restoration, the following coding is correct:

ToothCode
#29D6075 (correct)
#30D6245
#31D6075 (correct)

Here, the abutments on teeth #29 and 31 are correctly coded as fixed partial denture crowns.

Natural tooth single crown and fixed partial denture retainer crown codes are often used in error to code implant-supported prosthetics. Instead, they should be coded as fixed partial denture implant crowns.

Incorrect, coded as natural teethCorrect, coded as implants
D6740, #29 (incorrect)
D6056, #29
D6245, #30
D6740, #31 (incorrect)
D6056, #31
D6068, #29 (correct)
D6056, #29
D6245, #30
D6068, #31 (correct)
D6056, #31

If you receive a denial for single implant or fixed partial denture implant crowns, it may be one of the following:

  • 161. Benefits could not be determined because of missing/conflicting information
  • 7C2. The submitted procedure is not payable due to the absence or conflict of a related service.
  • 9WA. The fee for this procedure is considered to be part of, and included in the fee for, a completed service.

Alternate benefits when there is no implant coverage

Delta Dental’s standard plans pay an allowance or alternate benefit towards the cost of implant-supported prosthodontic appliances, subject to the same limitations as standard prosthodontic services. The allowance is based on the fee for a standard pontic procedure. The patient is responsible for any difference in the cost of the implant-supported procedure.

Denial codes for alternate benefits when there’s no implant coverage may be one of the following:

  • FLM. An alternate procedure/benefit has been applied.
  • 503. This service isn’t a covered benefit of the enrollee’s program. An alternate procedure/benefit has been applied.

Implant with natural tooth bridge

When dental implants are covered by a patient’s plan, the fees for the placement of an implant to support a hybrid natural tooth and implant-supported bridge will be denied. Under our guidelines, a fixed partial denture should be retained by either all natural teeth or all implants, not a combination of the two. In the absence of a stress breaker, implant/natural tooth hybrid bridges will be denied. Bridges anchored this way severely stress the natural tooth and the implant and eventually cause bone loss, mobility and bridge failure.

Denial codes for hybrid bridges may include the following:

  • 5A1. The long-term prospects of a tooth must be considered. Under our guidelines, a fixed partial denture should be retained by either all natural teeth or all implants, not a combination of the two.

Congenitally missing teeth

Implant placement will not be considered for the replacement of congenitally missing permanent teeth or for the correction of other developmental or congenital defects resulting in spacing due to migration or drifting of teeth.

Denial codes for congenitally missing teeth implant placement may include the following:

  • 511. Procedures to correct congenital or developmental malformations are not covered.

Associated denials related to implant procedures

X-rays

Pre-operative x-rays depicting each implant site are required to determine the payment of benefits on pre-authorizations. Post-operative x-rays of implant placement are required to determine payment of benefits on paid claims and must depict the entire implant. Implant length, width and location must be appropriate for the clinical condition and allow for adequate function of the implant-supported restoration/prosthesis.

Denial codes for x-rays may include the following:

  • 570. Benefits could not be determined because of missing pre-operative radiographic images.
  • 586. Benefits could not be determined because of missing post-operative radiographic images.
  • 5RX. Benefits could not be determined because the submitted radiograph does not depict the entire tooth.
  • 569. Benefits could not be determined because of the non-diagnostic nature of the radiographic images submitted.

Re-cementation of implant prosthetics

The code D2920 (re-cement or re-bond natural tooth crown) is often used in error to code re-cementation of implant prosthetics. The appropriate implant crown recement codes are as follows:

  • D6092 – Re-cement or re-bond implant/abutment supported crown
  • D6093 – Re-cement or re-bond implant/abutment supported fixed partial denture

Denial codes for re-cementation may include the following:

  • 788. A benefit allowance cannot be made for the requested procedure as our records show that this tooth was previously extracted.
  • 161. Benefits could not be determined because of missing/conflicting information.

Edentulous arches

For a completely edentulous arch, replacement of teeth and restoration of the occlusion can be adequately restored with four to six dental implants.

D6190 – Radiographic/surgical implant index, by report

When your patients’ plans include implant benefits, Delta Dental considers the fee for procedure D6190 to be included in the fee for the definitive treatment for one implant. A separate fee may not be charged to the patient or Delta Dental. Under contracts with implant coverage, procedure D6190 may be covered at the prosthetic benefit level when two or more implants are placed during the same treatment episode. If implants are not covered by the patient’s plan, this procedure is not a benefit, and the patient is responsible for the fee.

Denial codes related to D6190 may include the following:

  • 9WA. The fee for this procedure is considered to be part of, and included in the fee for, a completed service.
  • 7BB. This service is not a covered benefit of the enrollee’s plan.

D6011 – Second stage implant surgery

When implant services are covered by the patient’s contract, Delta Dental considers the fee for this procedure to be included in the fee for procedure D6010, surgical placement of implant body. A separate fee may not be charged to the patient or Delta Dental.

Denial codes related to D6011 may include the following:

  • 9WA. The fee for this procedure is considered to be part of, and included in the fee for, a completed service.
  • 718. This fee for this procedure is considered to be part of, and included in the fee for, a completed service.

D6199 – Unspecified implant procedure, by report

Please provide a narrative report with a complete description of the procedure and its rationale. Tools used, parts, healing caps, etc. will be considered inclusive in the implant procedure and not a separate benefit.

Denial codes related to D6199 may include the following:

  • 564. Submit clinical treatment narrative.
  • 9WA. The fee for this procedure is considered to be part of, and included in the fee for, a completed service.

Delta Dental’s processing policies for implants and the procedures and prostheses associated with them should be considered guidelines. Whenever an exceptional case is involved, please provide a full narrative description and any available supporting documentation to help our staff determine benefits. To ensure timely benefit determination, always submit the appropriate supporting documentation on your initial submission.

Why your SRP claims are denied and what you can do

Claims for periodontal scaling and root planing (D4341 and D4342) are denied more frequently than those for many other procedures, according to the American Dental Association.

Delta Dental defines periodontal scaling and root planing (SRP) as “a definitive non-surgical periodontal treatment involving the judicious and thorough planing of the root surface.” The procedure involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus.

Although you should always refer to the Delta Dental Dentist Handbook for specific processing policies and guidelines, we’ll highlight some common reasons for denials for SRP and associated procedures.

Documentation fails to support payment of SRP

Delta Dental considers a quadrant of procedure D4341 to consist of at least four diseased teeth (4-6mm pockets, early bone loss).

  • When fewer than four diseased teeth are involved, Delta Dental bases its allowances on procedure D4342.
  • In addition to qualifying pocketing, radiographs must show loss of alveolar crest height beyond the normal 1-1.5mm distance to the cemento-enamel junction (CEJ).
  • Exposure of cemental surfaces of the roots is necessary for root planing.
  • Without a reduction in the alveolar crest level, root planing isn’t achievable.
Qualifying: X-rays clearly shows appreciable bone loss and calculus
Non-qualifying: X-rays show no appreciable bone loss and calculus 

Denial code: 5F8. Submitted documentation fails to support payment of benefits for scaling and root planing.

Submission of more than two quads of SRP on the same date of service

Without supporting documentation, the fees for more than two quadrants of SRP performed on the same date of service are disallowed. Acceptable supporting documentation includes:

  • Clinical progress notes
  • Evidence of length of appointment (successful scaling typically takes 30-45 minutes per quadrant with local anesthesia)
  • Information about the local anesthetic used
  • The reason for performing more than two quadrants on the same date of service

Four quadrants of SRP may be approved on a pre-authorization when criteria are met. However, you’re expected to know the policy upon payment.

Denial code: 447. No more than two quadrants of scaling and root planing are allowable on the same date of service.

Inadequate periodontal charting or x-rays

The D4341 and D4342 procedures require you to submit periodontal charting that indicates at least Case Type II periodontal disease (4-6mm pockets, early bone loss).

  • Periodontal charting should be dated no more than 12 months before the date of service.
  • Full-mouth series or bitewings that clearly show appreciable bone loss are preferred because these images are usually the most accurate determinant of bone loss.
  • Submit corresponding images for each submitted quadrant.
Qualifying: Labeled periodontal charting that indicates exam date
Non-qualifying: X-ray is non-diagnostic as interproximal contacts are overlapped and fail to show bone loss

Denial codes:

  • 5F8. Submitted documentation fails to support payment of benefits for scaling and root planing.
  • 574. Benefits could not be determined because of missing periodontal charting.
  • 570. Benefits could not be determined because of missing pre-operative radiographic images.
  • 573. Benefits could not be determined because of missing full mouth radiographic images.
  • 569. Benefits could not be determined because of the non-diagnostic nature of the radiographic images submitted.
  • 426. Benefits could not be determined because of missing radiographic images, periodontal charting, and treatment record.
  • 5GB/5GC. Submit current periodontal chart, dated pre-operative diagnostic radiographs, and a copy of the patient treatment record.

Associated denials related to SRP

Gingival irrigation (D4921)

Gingival irrigation isn’t a separately payable procedure when provided in conjunction with SRP or any other periodontal procedures. You can’t charge a separate fee for the procedure to Delta Dental or the patient.

Denial code: 449. The fee for gingival irrigation is included in the fee for any periodontal services performed on the same date of service.

Localized delivery of antimicrobial agents (D4381)

This procedure isn’t a benefit under some plans and requires you to submit periodontal charting indicating pockets of at least 5mm. When submitted with nonqualifying SRP, these procedures will be denied due to conflict with the denied SRP.

Denial codes:

  • 7BB. This service is not a covered benefit of the enrollee’s program.
  • 7C2. The submitted procedure is not payable due to the absence or conflict of a related service.

Unspecified periodontal procedure (D4999)

These are most commonly submitted as bacterial decontamination, laser or irrigation.

Delta Dental considers specialized techniques, such as those that use lasers or antibacterial medicaments, to be included in the fee for any SRP or surgical procedure. You can’t charge a separate fee for the procedure to Delta Dental or the patient.

Don’t forget:

  • Delta Dental pays for completed procedures, not tools used for treatment.
  • Please provide a narrative report with a complete description of the procedure and its rationale.

Denial codes:

  • 440. The fee for this procedure is considered part of and included in the fee for periodontal services.
  • 9WA. The fee for this procedure is considered to be part of, and included in the fee for, a completed service.
  • 564. Submit clinical treatment narrative.

Delta Dental’s periodontal processing policies described above should be considered guidelines. Whenever an exceptional case is involved, please provide a full narrative description and any available supporting documentation to help our staff determine benefits.

And remember, to ensure timely benefit determination, always submit the appropriate supporting documentation on your initial submission.

CDT 2022 updates have arrived

The American Dental Association’s CDT procedure codes and nomenclature* have been updated for 2022. Changes include 24 new codes, five code deletions and 22 nomenclature and description revisions.

Please review our summary of changes and claims processing policies (PDF) and begin using CDT 2022 codes on claims for procedures provided on and after Jan. 1, 2022.

*CDT coding and nomenclature are the copyright and a trademark of the American Dental Association, all rights reserved.


Note: The PDF has been updated to allow printing.

New CDT codes for COVID-19 vaccination

In March 2021, the Code Maintenance Committee of the American Dental Association (ADA) added seven new codes designed to report the delivery of COVID-19 vaccine. These codes have been added to the preventive category of service.

Additionally, a new code for molecular testing has been added to the diagnostic category of service.

These services are covered under medical plans and therefore will not be covered by Delta Dental. If you administer COVID-19 vaccines in your dental office, check with your patients’ medical carriers for more information about coverage.

New CDT codes as of March 29, 2021:

  • D0606 — molecular testing for a public health related pathogen, including coronavirus. This procedure is not a benefit of most Delta Dental plans. The fee is the patient’s responsibility
  • D1701 — Pfizer-BioNTech Covid-19 vaccine administration – first dose. This procedure is not a benefit of most Delta Dental plans. The fee is the patient’s responsibility.
  • D1702 — Pfizer-BioNTech Covid-19 vaccine administration – second dose. This procedure is not a benefit of most Delta Dental plans. The fee is the patient’s responsibility.
  • D1703 — Moderna Covid-19 vaccine administration – first dose. This procedure is not a benefit of most Delta Dental plans. The fee is the patient’s responsibility.
  • D1704 — Moderna Covid-19 vaccine administration – second dose. This procedure is not a benefit of most Delta Dental plans. The fee is the patient’s responsibility
  • D1705 — AstraZeneca Covid-19 vaccine administration – first dose. This procedure is not a benefit of most Delta Dental plans. The fee is the patient’s responsibility
  • D1706 — AstraZeneca Covid-19 vaccine administration – second dose. This procedure is not a benefit of most Delta Dental plans. The fee is the patient’s responsibility.
  • D1707 — Janssen Covid-19 vaccine administration. This procedure is not a benefit of most Delta Dental plans. The fee is the patient’s responsibility.

Billing for orthodontics: your questions answered

Let’s get one thing straight — there’s a lot to know when it comes to orthodontic claims. No need to brace yourself for claim rejections, though! Use this handy guide to submitting orthodontic claims and you’ll be an ortho pro in no time.

How do I submit an orthodontic claim online?

You can submit claims online through Provider Tools. Register for an account, log in to your dashboard and select Submit claim. You only need to submit one claim at the time of the initial banding.

There’s no need to submit additional claims for monthly adjustments. Delta Dental calculates payment based on that first claim with complete treatment and fee information.

You can keep track of your claims by selecting My claims in the Provider Tools dashboard.

Graphic showing what you can do in Providers Tools, starting at the log in page and then the Provider Tools dashboard. It lists some things you can do in Provider Tools: fill in forms, make payments, file and view claims.

What information do I need to include on an orthodontic claim?

You can refer to pages 5–4 and 5–5 in our dentist handbook for general Delta Dental policy around orthodontic claims. Each plan may require different information, so make sure to look at your patient’s coverage in Provider Tools for specific requirements. While you’re there, you can also submit and track claims using the Submit claims and My claims tools!

For orthodontic claims, submit a single claim at the time of the initial banding with the following information:

  • a description of the dentition
  • the procedure code with a description of appliance and treatment
  • the banding date and estimated number of active treatment months
  • the total fee you intend to collect for services (including the initial down payment and monthly fee)

If applicable, you should also include the amount paid by a previous dental carrier, the name and procedure code of appliances used to control a harmful habit and any dual coverage information. You don’t need to submit x-rays or radiographs for claims unless specifically asked to do so by Delta Dental.

How are orthodontic claims paid?

Our allowances for orthodontic procedures include all appliances, adjustments, insertion, removal and post-treatment stabilization (retention). Calculations are based on the all-inclusive total treatment plan amount, subject to any deductible, the appropriate payment percentage and maximum amount.

Our first payment is 50% of the total amount payable. The remaining 50% is paid 12 months later.

For most plans, the orthodontic maximum is a lifetime maximum. Also, if the total amount payable is $500 or less, we pay the full amount in one payment when the claim is processed

Are there exceptions to the two-payment schedule?

Yes. If the patient’s plan has specific provisions for a different payment method, we will pay accordingly. Also, if treatment ends before our second payment is due, advise us that the bands were removed and the treatment has been completed. You may call Customer Service or submit a claim that includes this information.

How should fees for x-rays and study models be submitted?

Submit fees for these records along with the banding information or on a separate claim. If submitted separately, indicate on the claim that these records are in conjunction with orthodontic treatment. You don’t need to x-rays or study models to Delta Dental unless specifically requested.

Are retainers and harmful habit appliances covered?

Yes. Allowances include all appliances, adjustments, insertion, removal and post-removal stabilization (retainers).

Harmful habit appliances are covered if a patient’s plan includes a specific provision for minor treatment to control harmful habits. The provision must be in conjunction with orthodontic treatment (procedure code D8210) and/or separately (procedure code D8220).

Retainer repairs and replacements are not covered.

How do I submit claims for Invisalign, lingual braces or SureSmile?

Some plans cover alternative appliances like Invisalign, lingual braces or SureSmile. You can check if your patient’s plan covers clear aligners by visiting Provider Tools, clicking on My patients and selecting Check eligibility and benefits next to the name of the patient. Click Orthodontics under Benefit details to view limitations, age limits and coverage levels. There is no unique procedure code for clear aligners, so reference the CDT codes used for conventional treatments, D8010 through D8090.

Submit claims for clear aligners as a separate line item from the orthodontic treatment code and fee. Make sure to enter a complete description of the service, including reference to Invisalign, lingual braces or SureSmile.

How is payment determined when a patient switches to a new orthodontist?

We calculate remaining benefits based on the date of the first adjustment with the new orthodontist. The new orthodontist should submit a claim using the first adjustment date as the starting date of treatment, along with a notation that the patient has transferred from another office.

Are orthodontic benefits ever prorated? How?

Yes. Prorating occurs when an event affects the patient’s orthodontic coverage. New Delta Dental coverage after treatment has begun, an increase in existing coverage, a change in eligibility or a change of orthodontists might spur proration.

When Delta Dental prorates payments, we subtract the total fees for any treatment months that occurred before the patient’s effective date with Delta Dental from the total orthodontic treatment fee. Our amount payable is then based on the remaining treatment fee, the remaining number of treatment months and applicable payment percentage and maximums.

Why was my claim rejected?

Claims can be rejected for a variety of reasons. The most common rejections are for incorrectly entered patient information, like enrollee IDs or patients submitted as dependents. Make sure to include all relevant information on your claims, like multiple banding dates, multiple case fees and the correct length of treatments. Excluding this information may lead to a rejected claim We also see rejections for claims using CDT codes that have been deleted or revised, so stay on top of the latest CDT updates!

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