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Hi guest!
There are two modifiers that come to mind, one for indicating multiple surgeries/procedures performed on the same day, one for indicating that distinct procedural services.
Modifier 51 - multiple surgeries/procedures
(i.e. Multiple surgeries performed on the same day, during the same surgical session). This one would be appended to any procedures after the most expensive one for that date of service on the medical claim.
Modifier 59 - Distinct Procedural Service
(i.e. to indicate a procedure or service was distinct/independent from other non-E/M services performed on the same day. Used to identify procedures/services, other than Evaluation & Management (E/M) services, that are not normally reported together, but are appropriate under the circumstances)
Hope this helps!
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Hello,
Thanks for all the info. I would like to ask what kind of Remarks or Description for the Unusual Services section of the claim to justify the need of the Sinus Lift?
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Hi Courtney,
What Remarks would you put to justify the sinus lift at the same date as implant placement date?
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Hi
I was hoping I could some of the same help as others I suffer from Acid Reflex and a broken tooth, my dentist said I needed a D7952 Sinus Augmentation via a Vertical approach and they said that Blue Cross and Blue shied FEP does not cover it. any adivce
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Thank you for your help, very much appreciated
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Hi Guest! I found the following language in Aetna's medical policy titled: "Dental Services and Oral and Maxillofacial Surgery: Coverage Under Medical Plans": http://www.aetna.com/cpb/medical/data/1_99/0082.htmlIt states: "The following dental services are considered not covered under the medical plan regardless of whether they accompany medically necessary reconstructive surgery: - Dental implants (except as specified in the certificate of coverage). Most medical plans do not cover the routine replacement of teeth via surgical placement of a dental implant body. In addition, any procedures (e.g., bone replacement graft,sinus lift surgery, soft tissue graft, and barrier membrane placement) considered as adjunctive procedures to the surgical placement of the dental implant body are also not covered. For those medical plans that do cover routine replacement of teeth by dental implants, the only procedure covered by the medical plan related to the dental implant is the surgical placement of the dental implant body (replacement of the missing root). The restorative procedure (replacement of the missing crown) is considered a dental expense; - Fluoride carrier." However, if the reason for the sinus lift is not relating to implant placement, it would certainly be worth submitting a pre-authorization for review to your medical insurer. Hope this helps!
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Can anyone help me with a question. I have to have a sinus lift and I’ve been told that my dental plan which is Aetna will not cover it. I suffer from osteoporosis and acid reflex which has contributed to my loss of bone. Could I file a claim through my health insurance plan or is there another option to file through my dental plan. Any help regarding this matter is greatly appreciated. Thank you
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Hi RTilly!
Thanks for the kind words!
Great questions. The CPT code to use for sinus lifts:
21210 - Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)
**use modifier -52 for reduced services when bone is not obtained from patient
The pre-authorization request is typically submitted by the provider instead of the patient, as they will need information like your NPI and Tax ID to process this request. While some insurers may require that the patient's PCP initiates these types of requests to out of network providers, most medical insurers will accept the request from the dentist.
Hope this helps!
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Hi Courtneydsnow,
Your amazing responses are really helpful.
1. Do you have code for Anthem BlueCross PPO plan ?
2. Can the pre-approval letter submit by patient instead of Doctor?
3. If submission has to be filed by doctor, does it need to be a MD ? Or DDS? or dentist can, too ?
Thanks.
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Hi Guest!
No problem. Below are the updated coding options for moderate sedation services:
99151
Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intraservice time, patient younger than 5 years of age
99152
Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older
99153
Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; each additional 15 minutes intraservice time (list separately in addition to code for primary service)
99155
Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient younger than 5 years of age
99156
Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient age 5 years or older
99157
Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes intraservice time (list separately in addition to code for primary service)
Hope this helps!
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