What you don't know about Ortho Billing...
Your Ortho Questions Answered
1. Do I need to bill separately for an orthodontic workup? Is this a separate fee or part of the orthodontic treatment?
Whether or not a separate fee is charged for an orthodontic workup or included as part of the orthodontic treatment is a business decision to be made by the dentist.
2. Does the benefit paid for an orthodontic workup always come out of the orthodontic maximum?
The benefit payable for an orthodontic workup comes out of the orthodontic maximum under most patients’ contracts.
3. If a patient comes in for a visit and a panoramic film, and it is determined that the patient is too young to begin orthodontic treatment, can I charge for the visit and the panoramic film?
These procedures may be submitted using the appropriate procedure codes of D8660 for the pre-orthodontic treatment visit and D0330 for the panoramic film. They will be processed according to the patient’s orthodontic benefit.
4. What code(s) should I use for an orthodontic workup?
An orthodontic workup should be submitted using the appropriate CDT code for each procedure. The separate fees will be combined under CDT code D8999 and will be processed according to the patient’s orthodontic benefit, limited to the lesser of the submitted fees, filed fees, or the insurances maximum allowable charges (MAC) for each of the procedures.
5. How will an orthodontic workup be benefited if I am a general dentist rather than an orthodontist?
An orthodontic workup is processed according to the patient’s orthodontic benefit whether performed by a general dentist or an orthodontist.
6. Is a second orthodontic workup covered once Phase I is completed?
Orthodontic workups are processed according to the patient’s orthodontic benefit. Most plans allow one orthodontic workup for a provider for a full comprehensive orthodontic treatment plan. We always recommend billing every procedure completed because you never know when or how plans change.
7. What procedure codes should be used when there are multiple phases of treatment? Comprehensive orthodontic procedure codes should be used for multiple-phase treatment plans. Each phase is submitted as comprehensive treatment using the code that reflects the patient’s stage of dentition for that phase (transitional, adolescent or adult).
8. Do I need to send a second claim to receive additional payments? A second claim is necessary only if the patient’s orthodontic benefit is subject to a benefit year maximum. This is not the majority of cases. Most patients’ orthodontic benefits are paid according to an automatic payment schedule that does not require a second claim. The Explanation of Benefits for the initial claim will indicate if remaining benefits will be automatically generated according to a schedule.
9. What happens if a patient’s coverage is terminated during treatment? When coverage terminates during an active orthodontic treatment plan, the insurance company will prorate its payment. The number of months the patient was not eligible for coverage is deducted from the total months of treatment. Payment is based on eligible months of treatment. The payment is calculated by dividing the Insurance company's maximum liability for the entire treatment by the total months of treatment and multiplying that amount by the months of treatment during which the patient was eligible. This amount will be paid according to the orthodontic payment schedule of the patient’s plan.
10. If using clear aligners, what is needed for treatment to be considered for payment? How should it be coded? What additional information is needed? Treatment plans using clear aligners are processed according to the patient’s contract. They may be denied, or an optional benefit may be provided for conventional therapy, subject to all contract limitations and maximums for the conventional therapy. There is no unique procedure code for clear aligners; use the same procedure codes as for conventional treatment. Claims need to indicate that clear aligners are being used and must provide the same information as required for conventional treatment plans. Also, indicate any additional charges over and above your usual fee for conventional treatment, if applicable. The additional charges for these procedures are the responsibility of the patient under most patients’ plans.
11. If the patient is covered by dental insurance, but the patient has no orthodontic coverage, do I need to submit a claim form? Dentists should always submit a claim for all treatment performed on a patient, whether or not the particular service is covered so that the patient’s history is complete and so that an Explanation of Benefits can be provided indicating the patient’s responsibility for the treatment. The patient may need this for circumstances such as Coordination of Benefits or Flexible Spending Account reimbursement.
12. What happens if a patient has excessive breakage or needs to continually come into the office? Can I charge an additional fee? Will an additional benefit be payable? When submitting claims, any case with extenuating circumstances should be submitted with documentation for individual consideration. This documentation will be reviewed to determine if an additional benefit is payable according to the patient’s orthodontic benefit or if the patient should be responsible for additional charges.
13. How do you handle orthodontic pretreatments? Pre-treatment estimates are recommended for all orthodontic treatment. To request a pretreatment estimate, simply complete and submit an Attending Dentist’s Statement, making sure to provide all of the information needed for processing an orthodontic treatment plan. We will file these for your office with every patient who has an Ortho Consult/Ortho work up.
14. What should I verify when asking for eligibility? Here at Dentistry Support, we verify all insurance for all aspects of dentistry. Here is a snippet of the Ortho section of our customized Break down of Benefits form. This section is fully customized for your dental practice.
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