Friday, August 24, 2018

Basics of Dental Billing and vision care billing in APG payments


Dental services provided in the clinic setting (hospital or free-standing) are to be billed using the APG payment methodology. The only exception to this policy is orthodonture, which is to be billed to the dental practitioner fee schedule and not to APGs. Orthodontic procedures are identified as those D codes grouping to APG 371 – Orthodontics. Again, APG 371 is a non-payable APG. Providers will continue to be required to obtain prior approval for orthodontic procedures. E&M codes should not be billed for any dental services. All dental services should be billed using only D codes Effective January 1, 2010, medical visits will no longer package with dental procedures or exams. When a patient has a medical visit (i.e., with a practitioner other than a dentist) and a dental visit on the same day, both the medical visit and the dental exam will pay at the line level.

Effective February 1, 2010, dental professional services are included in the APG payment to the facility and may not be billed by dentists using the Medicaid dental fee schedule. Specifically, no D codes (other than those used for orthodonture) are billable against the practitioner fee schedule. Dentists and/or oral surgeons should not bill Medicaid fee-for-service for non orthodontic D codes but may submit a claim for their professional services to the facility (i.e., the APG biller). If a practitioner is enrolled in Medicaid as both a dentist and a physician he/she may submit a separate [non-APG] professional claim for services payable off the physician schedule. If a procedure requires three encounters to complete, a clinic should claim for the applicable procedure code for each distinct date of service. However, APGs 373 Level I Dental Film, 374 Level II Dental Film, and 375 Dental Anesthesia will not pay if there are no other procedures claimed for the applicable date of service. For dates of service beginning January 1, 2009, when multiple dental procedures are performed on the same date of service, the highest weighted procedure will pay at 100% and all other dental procedures will be discounted (at 50%). This will be the case even for procedures that group to the same APG. Multiple same APG consolidation has been eliminated for dental services.

The procedure code for dental sealants (D1351), should be coded once for each tooth that is sealed on a single date of service. If four teeth are sealed during a visit, the code D1351 should appear on each of four claim lines, each with the same date of service. Beginning on January 1, 2011, dental sealants will become a units-based procedure, to be coded on only a single claim line – with the number of teeth sealed shown in the units field. The following are the dental ancillary procedure APGs: 373 Dental Film, 374 Level II Dental Film, 375 Dental Anesthesia, 376 Diagnostic Dental Procedures, and 377 Preventive Dental Procedures. All dental ancillaries pay at the line level. Multiple ancillaries that group to the same APG will be discounted by 50%, whereas multiple ancillaries that group to different APGs will be paid at 100%.

For APG dental billing the 837i claim format must be used, not the 837d claim form.

Dental code D9920 -- behavior management (for patients with mental retardation or a developmental disability) groups to APG 999 and will not pay under the APG reimbursement methodology.

Reimbursable services provided to recipients with recipient exception codes 81 or 95 will receive a 20% higher operating payment. This rate enhancement will begin July 1, 2010 for hospital clinics (using rate code 1501 for visit billing or 1489 for episode billing). Immediately upon the D&TCs transition to the APGs, and retroactive to September 1, 2009, free-standing clinics will receive the 20% rate enhancement for MR/DD/TBI patients under rate code 1435 (the MR/DD/TBI episode rate code 1425 is pended due to the lack of CMS approval of the Dec. 2009 D&TC State Plan Amendment).

Effective April 1, 2010, oral sedation in dentistry (D9248- Sedation (non-iv)) will be paid based on a procedure based weight. This code is to be used only for MR/DD/TBI recipients (as defined by recipient exception codes 81 or 95). Since there are currently no edits in place relative to this code, it is possible to improperly bill for this code. As with any violations of Medicaid billing policy, improper claims are subject to take back accompanied by possible legal action. Please check for the recipient eligibility prior to billing D9248.


Most vision care services are covered in the APG payment methodology. However two vision care services; “the fitting of spectacles: monofocal, bifocal, or multifocal” , “the fitting of spectacles and the eyeglass materials” are carved out of APGs and are billed using rate codes 1226 and 1227 respectively.

4.4 ANCILLARY LABORATORY SERVICES AND RADIOLOGY PROCEDURES: Under the new APG payment methodology, payment for laboratory and radiology services ordered by practitioners in hospital-based outpatient clinics is made to the clinic. When the hospital or D&TC patient receives the ancillary service from someone other than the clinic, the clinic is responsible for paying the individual or entity providing the ancillary service, even in the absence of a contractual relationship between the two parties. The ancillary service provider may not bill Medicaid directly for lab or the technical component of radiology services related to an APG-reimbursed visit and therefore must bill the ordering clinic for the service provided to clinic patients. This ancillary billing policy will be implemented prospectively in DTCs, effective January 1, 2011.

For example, when a practitioner in Clinic A orders a lab test or radiology service that it is not able to provide and the patient goes to Provider B (separate hospital, lab or a radiology group) to receive the service, Clinic A will be responsible for billing eMedNY for the ancillary service and making arrangements to pay Provider B for the delivery of the service. Clinic providers may wish to develop or revisit existing contractual arrangements with laboratory and radiology providers to ensure the availability of ancillary services for their patients and to avoid payment issues upon the implementation of the new APG payment methodology. This payment policy also applies to hospital ED units in the event that the ED physician orders an ancillary laboratory or radiology service that is provided to the patient subsequent to the ED visit.

Hospitals are and effective January 1, 2011 D&TCs will be responsible for advising outside lab and radiology service providers on the order for the service when the payment for the ancillary service is subject to APG reimbursement and the APG ancillary billing policy. They must also advise radiology service providers if they want the provider to “read” the radiology results and bill Medicaid directly for these professional services. Alternatively, if the hospital provider plans to bill for “reading” the radiology result, the hospital should advise the radiology vendor not to bill for the professional component of the radiology service. Only one professional component per radiology procedure per recipient may be billed to Medicaid.

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