CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Payment Policy Dental Providers Filing Evaluation and Management for Medical Reasons

Defines when dental providers may file E/M services for medical indications (e.g., pre-transplant, pre-radiation) and distinguishes coverage between Oral/Maxillofacial Surgeons and other dental provider types for BlueCHiP for Medicare and commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyDental Providers Filing Evaluation and Management for Medical Reasons

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 6, 2009

Next Review DateN/A

Key ActionPrior authorization is not required; file E/M codes 99201-99215 only when billed by an Oral/Maxillofacial Surgeon for medical indications.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

99201-99215E/M codes allowed when filed by an OMS

41899Unlisted dentoalveolar procedure code

BlueCHiP for MedicareMedicare product allows inpatient oral/dental exams

Commercial limitationE/M by non-OMS dental providers not covered

When E/M Services Are Covered

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Coverage rules by product

Coverage depends on product and provider type; specific instructions for claim filing and modifier use apply.

Product-specific coverage rules:

BlueCHiP for Medicare

An oral or dental examination (not treatment) on an inpatient basis performed as part of a comprehensive workup to transplantation or heart valve replacement surgery is covered for all dental providers (including OMS, general dentist, periodontist, endodontist, orthodontist, prosthodontist, and pedodontist).
Dental providers are covered for extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw under the member's medical benefit; follow special filing and claims instructions (see Reimbursement/Claims section).

Commercial

Evaluation & Management (E/M) services for oral examinations are covered only when rendered and filed by an Oral/Maxillofacial Surgeon (OMS) for a medical condition.
E/M services for dental examinations reported by other dental providers (general dentist, periodontist, endodontist, orthodontist, prosthodontist, pedodontist) are not covered.

Billing guidance applicable to all products

The following E/M codes are covered when filed by an OMS for a medical condition: 99201-99215.
An OMS may append modifier GA (waiver of liability statement on file) when filing an E/M for a non-covered, non-medical condition; when filed with GA the claim will deny as non-covered and the member will be liable.

Codes and Provider Restrictions

E/M codes covered for OMSCPTCovered

99201-99215

Evaluation and Management service codes covered when filed by an Oral/Maxillofacial Surgeon for a medical condition

Unlisted dentoalveolar codeCPTCovered

41899

Unlisted procedure, dentoalveolar structure

Provider type restriction — E/M coverage for OMS

Provider restrictionEvaluation & Management (E/M) codes 99201-99215 are covered only when filed by an Oral/Maxillofacial Surgeon (OMS)

Applicable codes99201-99215

Claim filing noteIf an OMS files E&M for a non-covered, non-medical condition they may append GA modifier; such claims will deny and member will be liable

Billing, Prior Authorization, and Modifier Guidance

Prior Authorization

Prior authorization: Not applicable.

Denial Risk

Modifier guidance / Member liability

An OMS may append the GA modifier when filing Evaluation and Management (E&M) services for non-covered/non-medical conditions. When billed with GA, the claim will deny as non-covered and the member will be liable for payment.

Covered E&M codes when billed by an OMS for medical conditions: 99201-99215
Use GA modifier to indicate a signed Advance Beneficiary Notice/waiver of liability when filing for non-covered/non-medical conditions
Claims billed with GA for non-covered services will deny; member financial responsibility applies

Medical and Dental Condition Definitions

Medical conditions (examples)

NeoplasmsIncludes malignant or benign neoplasms of the lip, tongue, or floor of the mouth

Salivary gland diseaseDiseases of the salivary glands are included among medical conditions

Cyst removalCyst removal from the area of the mouth is considered a medical condition indication

Pre-treatment workupsPreparation for radiation treatments and pre-transplant or heart valve surgery workups are medical indications for oral examinations or interventions

Dental conditions — coverage boundary

General dental servicesServices for care, treatment, removal or replacement of teeth and directly supporting structures (periodontium) are not covered as a medical benefit

Exception — medical indicationsDental procedures may be covered as medical benefit when required for specific medical indications such as preparation for radiation for neoplastic disease

Definition of supporting structuresSupporting structures include gingivae, periodontal membrane, cementum, and alveolar bone (alveolar process and tooth sockets)