Dental Terminologies III

Pre-Authorization / Pre-Determination:

A pre-Auth or Pre-D, is a prior approval that needs to be obtained from the insurance company prior to doing a particular treatments. It is similar t a claim form, the only difference is the treatment is not yet performed. Some insurance carriers / Plans need that the provider sends then a Pre-Auth / Pre_D for any treatment that is over a specified dolled value.

We need to make sure we understand ehat the insurance rep says, if they say it is Recommended it means they will make payments even if you do not submit a pre-D. But if they say it is Required, it means they will deny the claim if you perform the treatment without sending in a Pre-D.

Ways to Ask this question: Is pre Auth, mandatory (which means Required)? (Y/N), if answer is yes then we need to ask, "will the procedure be denied if we do not pre-auth?" If still yes then we need to ask for what is the minimum approval amount?"

Seat Date:

In case of procedure like Crowns, Dentures, Bridges some insurance companies will make payment based on Seat Date, which is the date the Crown, Denture or Bridge was actually Delivered to the Patient and Seated. Some will pay on the Preparation Dates, known as Prep Date. Most of the breakdown forms will have a question like, Are Crowns paid on Seat Date or Pre Date?" Based on the information the rep gives us the dental office will know on what date they can bill out the claim.

FMX (CDT ode is 00210):

FMX stands for Full Mouth X-ray, as the name suggests it is a complete series of X-rays of all the teeth. It includes 14 periapicals and 2 or 4 bitewings. Also known as a complete series.

Bite Wings (B/W); (CDT COde is 00270 to 00277):

Bite Wings is an X-rays that shows only the crown portion of  the upper and lower posterior teeth biting together on the same film. There can be a single film B/W (00270), two films (00272), 3 film (00273), 4film (00274). This is the most commonly used type of B/W and will always be a question on your breakdown form. So if the rep tells you they cover 4 films once in one year, it means you can do a 4 films bite wings (00274) only on e time in one year. A very common mistake that we make is we will update 4 times in one year, which is completely incorrect. So pay attention to this. Lastly there is also a 7 film b/w (00277), which is not commonly used.

Panoramic X-rays (CDT Code 00330 also Known as Pano):

It is an X-ray taken by a machine that rotates around your head t give the orthodontist a picture of your teeth, jaws and other important information. An x-ray taken outside of the mouth that shows all the teeth on one film. This is similar to an FMX, the difference is a Pano is one single x-ray, where as a FMX comprises of multiple x-rays.

Composite Fillings (CDT Code is 02390 to 02394):

This is a Tooth color filling, hence it looks very natural. These filling are a little more expensive compared to a Silver Filling, which is known as Amalgam Filling. Very often most insurance carries will downgrade a Composite Filling on the Posterior Teeth (CDT code 02393) for behind teeth and pay for an Amalgam filling rate instead. The patient would be responsible for the difference between the composite filling and what the insurance pays. Hence most of your breakdown forms will have a question on downgrades and asking this is very important.
Amalgam Filling: CDT Code 02140, 02150, 02160 and 02161. This is a Silver Color Filling.

Sealant (CDT COde 01351):

Clear application of acrylic placed over the biting surface of the tooth to prevent decay. Most insurance companies only allow hese on permanent teeth. These are mostly covered for Children only, hence most of your breakdown forms will have an AGE Limitation question linked to Sealants.

Bruxism: 

Bruxism is Clenching / Grinding of the teeth.

Night Guard:

A removable acrylic appliance to minimize the effects of grinding the teeth (bruxism) or joint problems (T.M.J.). Usually worn at night to prevent the grinding of teeth or relieve joint pain. Also known as an occlusal guard.

Prophylaxis (CDT Code 01110 (Adult) or 01120 (Child): 

It is also known as Phrophy. This is a regular cleaning of the teeth. This treatment is subject to a frequency limitation as well as age limitation.

Fluoride (CDT COde 01203 (Child) or 01204 (Adult):

A chemical in most brands of toothpaste and often added to water that binds with the tooth's surface, making it harder (less soluble) and more resistant to decay. This treatment is also subject to a frequency limitation as well as age limitation.

Perio Maintenance (CDT Code 04910): 

leaning of teeth following periodontal treatment includes perio charting. Procedure Code 04910. Also known as perio prophy or perio recall. This is a very common question on most of the Breakdown forms. Some insurance carriers will include the frequency of 04910 along with the frequency of regular cleaning (Known as Prophy 01110). So if your breakdown form has question for  Frequency of 04910, make sure you check with rep if this frequency is included with the frequency of a Prophy and update your form accordingly.

Scaling and Root Planning (CDT Code 04341):

Deep cleaning of the teeth to remove calculus below the gum-line. This is not a prophylaxis. This is a periodontal procedure and is usually performed one quadrant at a time. A common question on most of the breakdown form is, "Are all 4 Quads allowed 

in one visit?" Because some may not. This is similar, to the frequency is once in 2 years, this means that we can do each quad one in 2 years.  A common mistake that we make is we tend to update 4 in 2 tears, which is incorrect.