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Hello!
My experience has been fairly positive w/ Medical Insurance companies here in town being fairly forgiving in processing dental services due to accidents. I just got my first denial and am unsure of what it is they are asking of me.
Patient had accident and spent several days in hospital. Accident date 8/11/2020 and entered as such in box 14.
I thought my diagnosis code was X58.XXXA (box 21 A) based on previous experience with another local medical insurance company who indicated this was appropriate for 1st visit to DDS after accident to address teeth injured in accident. Services billed 8/14/2020 have Diagnosis Pointer A listed for each service.
I thought I was being smart and included second visit as well on the same claim (different date of service) w/ diagnosis code: X58.XXXD - subsequent encounter (box 21 B). Date of service 8/28/2020 follow up service has Diagnosis Pointer B listed.
Claim rep called today saying claim was denied and needed "Primary accident diagnosis code and condition related to field box 14." Don't I already have this? I don't know enough to feel confident saying I do... it doesnt help the gal who called to relay this info isnt familiar w/ claims either and could only read verbatim what was in front of her. My only other thought is they don't like 2 service dates on one claim. Anything jumping out to you?
THANK YOU!
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Rank: Administration
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Hi Guest!
Great question. So, X58.XXXA stands for:
Exposure to other specified factors, initial encounter
So, i think what this insurer is likely looking for is going to be the code(s) to represent the trauma/damage/injury to the teeth, and then a code to represent how the accident happened.
For example, some common ones used for the injury part are:
S02.5XXA - Fracture of tooth (traumatic), initial encounter for closed fracture
S02.5XXB - Fracture of tooth (traumatic), initial encounter for open fracture
S03.2XXA - Dislocation of tooth, initial encounter
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
As for the code on how the accident happened, there are thousands! If you'd like to give me description of what happened (did the patient fall? get hit with something? vehicle or sports accident? etc etc) then i will be happy to offer you some coding options :)
Hope this helps!
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Rank: Guest
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Oh my gosh - thank you! Sounds like we would use S02.5XXA for his first visit. Would I use another code then for subsequent visits for the treatment of this tooth/teeth? He was in a (pedal) bike accident. I did a quick search and since it seems unclear as to whether it was a hit and run or not (police suspect, pt unconscious and found this way/no memory of accident since) I think I should use V19.9XXA. Thoughts? I then would use this code of the accident as a secondary diagnosis code? This is such an awesome resource after attending your classes. Thank you. Thanks again! Edited by user Wednesday, October 7, 2020 4:10:43 PM(UTC)
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Rank: Administration
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Hi Guest!
No problem, my pleasure!
Great find, yes based on what you described,
V19.9XXA - Pedal cyclist (driver) (passenger) injured in unspecified traffic accident, initial encounter
is what i would have chosen as well. unless it is confirmed how it actually happened.
And yes, the accident code is typically listed as a secondary code. You may also consider an acute pain code, if applicable:
G89.11 - Acute pain due to trauma
And thank you for the kind words, we're so glad it's helpful!
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Rank: Guest
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Thank you!
One last question. When I use S02.5XXA at his first visit, would I use another code then for subsequent visits for the treatment of this tooth/teeth?
Meaning, is the "initial encounter" description in relation to his actual first visit to our office due to this accident and I need to use another code for follow up appointment/services?
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Rank: Administration
Joined: 11/21/2012(UTC)
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Hi Guest!
Great question - yes! Here are the subsequent as well as sequela codes for this category below :)
S02.5XXD - Fracture of tooth (traumatic), subsequent encounter for fracture with routine healing
S02.5XXG - Fracture of tooth (traumatic), subsequent encounter for fracture with delayed healing
S02.5XXK - Fracture of tooth (traumatic), subsequent encounter for fracture with nonunion
S02.5XXS - Fracture of tooth (traumatic), sequela
Hope this helps!
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