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Guest
#1 Posted : Sunday, April 18, 2021 8:44:21 PM(UTC)
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Guest

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Joined: 9/8/2012(UTC)
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Hello,

First I just want to say thank you to those who run this amazing site. It has helped me find a lot of the information I need. However I'm looking for help with a claim issue.

I'm a patient, not a professional. I lost 3 teeth in an accident. Fortunately my medical insurance covers accidents to sound natural teeth. Unfortunately, my dentist doesn't deal with medical insurance, only dental, so I'm left with filing the out-of-network claim myself. They also told me they know nothing about medical coding.

Thanks to this site figured out the medical codes I need.

I've managed to figure out that D6051 (Interim implant abutment) and D6085 (Provisional implant crown) both use CPT code 41899 (Unlisted procedure, dentoalveolar structures).

Since this is 3 teeth times 2 codes per tooth, I had to file a claim that used code 41899 6 times. My insurance company, Anthem, rejected the claim with the note "Quantity billed exceeds CMS Medically Unlikely Edits (MUE) limit. Rebill within MUE limit if appropriate.".

I called the Anthem help line and asked what to do and they were able to tell me that you can only use code 41899 3 times before running into the MUE limit, but when asked what the proper way to bill this is, they said "sorry we aren't coders, we can't help with that." I also asked if it was possible to just use the D-codes and they told me that Anthem doesn't accept them.

I'm guessing that there is some magic code I need to enter to get around the MUE limits, but my searching of the internet has failed to reveal exactly what I need. Does anyone know how to do this?

Thanks in advance,
- A patient who is learning about your complicated world
courtneydsnow
#2 Posted : Monday, April 26, 2021 10:05:23 AM(UTC)
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courtneydsnow

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Joined: 11/21/2012(UTC)
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Hi Guest!

Thank you for the kind words, we're so happy this forum has been helpful to you!

And great question. Based on what you described, here is what I would suggest:

Go ahead and list 41899 just twice on the claim - 1 will represent the 3 D6051's, and 1 will represent the 3 D6085's.
Instead of using it for each tooth, use it for the service and combine the fees for the 3 instances of it (for three teeth) onto one line item.
Then, you can indicate the "supplemental information" that each code is being used for three different instances on different teeth, which will explain the increase fee for that line item.

So, here's how you indicate teeth numbers on the medical claim:

In the "supplemental information" area of the line item (the red shaded line that is typically left blank), you will enter "JP" followed by the tooth numbers, and "ZZ" followed by a short description of what services that code is being used to represent.

ZZ means "narrative description to follow", and "JP" means "tooth number(s)"

So it would look something like this (i'm making up the tooth number, so be sure you put in the correct ones!)
JP10 11 12 ZZinterim implant abutment


Examples of how this would look on the medical claim can be found in the NUCC's CMS 1500 claim form manual here, starting on page 46-48:
https://nucc.org/images/stories/PDF/1500_claim_form_instruction_manual_2020_07-v8.pdf

Hope this helps!
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