Hello . We billed to medicare for 21248 and 21215 (52). For 21248 we used K08.423. For 21215 we used K08.22. Claim was denied because they considered these ICD codes routine .
what was wrong?

Thank You

THANK YOU . So , what icd10 codes can we use that get paid..Patient cannot stand any removable prosthesis. And she needed bone graft for sure before implants .
What codes Medicare would consider as medical necessity?
Thank You
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Hi Guest!

Great question. The diagnoses that establish medical necessity for bone grafts and implants do vary from insurer to insurer. However, some diagnoses/situations where we typically see coverage are items like:

- Trauma/accidents - of course there are many different diagnostic codes available to represent different traumas and injuries, but a few common ones:

K08.411 - Partial loss of teeth due to trauma, class I
K08.412 - Partial loss of teeth due to trauma, class II
K08.413 - Partial loss of teeth due to trauma, class III
K08.414 - Partial loss of teeth due to trauma, class IV
K08.419 - Partial loss of teeth due to trauma, unspecified class
S02.5XXA - Fracture of tooth (traumatic), initial encounter for closed fracture
S02.5XXB - Fracture of tooth (traumatic), initial encounter for open fracture

- Tumors/cysts/abscess - again there are many, but here are a few examples:
K12.2 - Cellulitis and abscess of mouth
K04.6 - Periapical abscess with sinus
K04.7 - Periapical abscess without sinus
K09.0 - Developmental odontogenic cysts
K09.1 - Developmental (nonodontogenic) cysts of oral region
K09.8 - Other cysts of oral region, not elsewhere classified
K04.8 - Radicular cyst
C03.0 - Malignant neoplasm of upper gum
C03.1 - Malignant neoplasm of lower gum
C03.9 - Malignant neoplasm of gum, unspecified
C04.0 - Malignant neoplasm of anterior floor of mouth
C04.1 - Malignant neoplasm of lateral floor of mouth
C04.8 - Malignant neoplasm of overlapping sites of floor of mouth
C04.9 - Malignant neoplasm of floor of mouth, unspecified
C05.0 - Malignant neoplasm of hard palate
C05.1 - Malignant neoplasm of soft palate
C05.8 - Malignant neoplasm of overlapping sites of palate
C05.9 - Malignant neoplasm of palate, unspecified
C06.1 - Malignant neoplasm of vestibule of mouth


For Medicare specifically - their stance on dental services is that "Currently, Medicare will pay for dental services that are an integral part either of a covered procedure (e.g., reconstruction of the jaw following accidental injury), or for extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw." - here is a link to their statement:

https://www.cms.gov/Medicare/Coverage/MedicareDentalCoverage/index.html

Hope this helps!