Dentists and board eligible and board certified oral and maxillofacial surgeons must use the physician’s CPT procedure codes when billing complex oral surgery to PrimeWest Health. To receive reimbursem*nt for CPT procedure codes, the provider must be individually enrolled with PrimeWest Health.
Dentists using CPT procedure codes and coding must select the code for the procedure or service which most accurately identifies the service performed. Any additional procedures performed, or pertinent special services, must also be listed. When necessary, list any modifying or extenuating circ*mstances.
Any service or procedure must be adequately documented in the member’s medical record. Medical services provided by a dentist must be billed using current CPT procedure codes on the 837P.
Modifiers
Modifying medical procedure codes indicates that a service or procedure has been altered by some specific circ*mstance, but has not changed in its definition or code. The use of modifiers eliminates the need for separate procedure billings. Modifiers must be used when applicable. Please refer to the CPT manual for specific information on modifiers.
Multiple Surgeries
- Modifier 51 is no longer required on multiple surgeries performed on the member on the same day by the same provider
- PrimeWest Health follows Medicare guidelines (highest valued procedure at 100 percent; subsequent procedures at 50 percent)
- Subsequent claims for the same member on the same day by the same provider will be denied
- Providers should replace the original claim with a claim that includes all surgeries performed
Assistant Surgeon
An assistant surgeon is allowed for some complex procedures. If a medical procedure requires authorization and an assistant will be used, include this information with the authorization. A separate entry for the assistant surgeon is not required on the authorization requests. When billing for the assistant surgeon, use the authorization number given to the primary surgeon.
Miscellaneous Services
CDT codes: D9120 – Fixed partial denture sectioning and D9612 – Therapeutic parenteral drugs, two or more administrations, different medications do not require authorization, but are subject to utilization review. When billing, provide the drug name, dosage, and method of administration.
PW_11-18_444
Updated_11/01/2018
