7 Claims and Payment - Premera Blue Cross

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Premera Dental Reference Manual Premera Blue Cross Blue Shield of Alaska CDT 2009 - Description Documentation Requested 2010 D3346 - Retreatment of previous root canal Date of initial root canal therapy D3348 therapy If re-treatment done less than 12 months from initial root canal therapy, need preoperative x- rays and chart notes and/or narrative D4210 - Gingivectomy or gingivoplasty Periodontal charting D4211 periapical x-rays if billed with crown lengthening indicate specific tooth or teeth in quad performed D4230 - Anatomical crown exposure Periapical x-rays D4231 Periodontal charting indicate specific tooth or teeth in quad performed D4240 Gingival flap procedure Periodontal charting D4249 Clinical crown lengthening – hard tissue Periapical x-rays and periodontal charting D4260 - Osseous surgery Periodontal charting D4261 Indicate specific tooth or teeth in quad performed D4263 - Bone replacement graft Preoperative x-rays and periodontal charting D4264 D4265 Biologic materials Preoperative x-rays and periodontal charting D4266 - Guided tissue regeneration Periapical x-rays and periodontal charting D4267 D4271 - Tissue grafts Periodontal charting D4273 D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis Justification such as chart notes or narrative detailing the last time since last cleaning and/or periodontal services. D4381 Localized delivery of antimicrobial agents via a controlled release vehicle Name of material used (Arestin, Actisite, Atridox, Periochip) into diseased crevicular tissue, per tooth, Periodontal charting by report Tooth number(s) Narrative detailing patient’s active periodontal history D4910 Periodontal maintenance Narrative detailing patient’s active periodontal D5110 - D5281 D5410 - D5761 D5810 - D5821 D6010 - D6050 D6056 - D6077 history Periodontal charting Complete and partial dentures Age of prior denture (if any) Adjust, repair, replace, rebase, reline Initial placement date Impression(prep) and delivery(seat) dates denture Interim complete or partial denture Length of time interim denture will be used Surgical placement of dental implant Preoperative x-rays, chart notes, and periodontal charting Prognosis of implant Full treatment plan for patient Implant supported crown, fixed or X-rays and chart notes removable denture, and fixed partial List of all missing teeth Claims and Payment Chapter 7 Page 16
CDT 2009 - 2010 Description Premera Dental Reference Manual Premera Blue Cross Blue Shield of Alaska Documentation Requested D6194 denture List of all existing bridgework and dentures D6205 - Fixed partial dentures (bridge) Preoperative x-rays, prep and seat dates D6794 List of all missing teeth in both arches List of all existing bridgework and/or dentures in both arches If prior bridge or denture, need date of prior placement D6793 Provisional retainer crown Length of time provisional retainer crown will be D6970 - D6973 used Core buildup, post and core Preoperative x-rays Narrative detailing existing restorations and areas of new decay and/or defects If prior fixed partial denture, need date of prior placement D7230 - Surgical extractions Pre-operative x-rays and chart notes/op report D7241 D7260 - Oroantral fistula or sinus perforation Pre-operative x-rays D7261 closure Narrative or surgical operative report D7285 - D7288 Biopsy of oral tissue, brush biopsy, exfoliative cytological sample collection Pre-operative x-rays or lab/pathology report and chart notes D7410 - D7461 Removal of tumors, cysts, and neoplasms Pre-operative x-rays or lab/pathology report and chart notes D7610 - Treatment of fractures If dental accident provide: D7780 Pre-post op x-rays of teeth involved and office records/chart notes Date of accident and any third party information Condition of teeth prior to the accident D7810 - Reduction of dislocation and Diagnosis D7877 management of other temporomandibular Chart notes and narrative joint dysfunctions Description of service or equivalent medical code D7880 Occlusal orthotic device, by report Name and type of appliance including materials used in processing Diagnosis and narrative of the patients symptoms Treatment plan D7950 Osseous, osteoperiosteal, or cartilage Narrative and chart notes graft Preoperative x-rays D7951 Sinus augmentation with bone or bone Preoperative x-rays and complete treatment plan substitutes D8000 - Orthodontia Date the orthodontia appliance was placed D8999 Total cost of orthodontia treatment D9110 Palliative (emergency) treatment of dental pain Banding fee and initial down-payment Monthly adjustment fee (can bill monthly, quarterly etc.) Expected length of treatment in months. Chart notes, office records, or detailed narrative Claims and Payment Chapter 7 Page 17
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