DENTISTRY GROUND RULES
CPT only copyright 2004 American Medical Association. All Rights Reserved.
95
1. GENERAL:
The allowable fee for any dental service or procedure is the provider’s usual and customarycharge or the maximum fee schedule allowance, whichever is less. The maximum fee scheduleallowance for a particular service or procedure is determined by multiplying the listed Unit Value by thecurrent dollar Conversion Factor applicable to dentistry. The Unit Values and Conversion Factor fordentistry are not applicable to any other section of the fee schedule.
2. UNLISTED SERVICE OR PROCEDURE:
When an unlisted service or procedure is performed, theprocedure should be identified and the amount charged substantiated " by report" (BR).
3. PROCEDURES LISTED WITHOUT A SPECIFIED UNIT VALUE:
"BR" in the Unit Value columnindicates that the amount charged for this service shall be determined "by report" because the service istoo unusual or variable to be assigned a Unit Value. Pertinent information should be furnishedconcerning the nature, extent, and need for the procedure or service, the time, skill, and equipmentnecessary, etc.
4. MATERIAL SUPPLIED BY A DENTIST:
Supplies and materials provided by a dentist (e.g., sterile trays,supplies, drugs) over and above those usually included with the office visits or other services renderedmay be listed separately. Statement of charges will need to reflect any drugs, trays, supplies, andmaterials that were provided. Payment shall not exceed the cost of the item(s) to the dentist plus 25% ofthe cost or the cost of the item(s) plus $15.00 per item,
whichever is less
.
5. CONCURRENT CARE:
When the condition of the patient requires the skills of two or more dentists orhealth care providers to treat different conditions, payment is due each dentist or health care providerwho plays an active role in the treatment program. The services rendered by each dentist or health careprovider shall be distinct, identifiable, and adequately documented in the records and reports.
6. ALTERNATING DENTISTS AND/OR HEALTH CARE PROVIDERS:
When dentists or health careproviders of similar skills alternate in the care of a patient (e.g., partners, groups of same facility, coveringproviders on weekends or vacation periods), each dentist and health care provider shall chargeindividually for the services personally rendered; such charges shall be in accordance with this FeeSchedule.
7. PRORATION OF SCHEDULED FEE:
When the schedule specifies a Unit Value for a definite treatment,and the patient is transferred from one dentist or health care provider to another, the applicable UnitValue is to be apportioned between the health care providers. The providers involved shall agree uponthe amount of proration, and shall render separate bills accordingly with an explanatory note.
8. MODIFIERS:
Procedure codes for dentistry may be modified under the circumstances described below.The circumstances are to be identified by the addition of a hyphen and the appropriate two-digit modifiercode. The modifiers that may be used are as follows:-22 Unusual Services: A report is required.-52 Reduced Values: Under certain circumstances, the listed value for a procedure isreduced or eliminated because of common practice, or at the dentist’s election.-53 Primary Emergency Services: When a dental procedure is carried out by adentist who will not be providing the follow-up care, the value shall be 70% of thelisted value.-54 Surgical Procedure Only: When one dentist performs the surgical procedure itselfand another provides the follow-up care, the fee may be apportioned betweenthem. Identify the dentist performing the surgery with this modifier. The “globalfee” is not to be increased, but prorated between the dentists.
DENTISTRY GROUND RULES
CPT only copyright 2004 American Medical Association. All Rights Reserved.
96
-55 Follow-Up Care Only: When one dentist performs the main procedure itself andanother provides the follow-up care, the value may be apportioned betweenthem. Identify the dentist providing the follow-up care with this modifier. The“global fee” is not to be increased, but prorated between the dentists.-56 Pre-Operative Care Only: When one dentist performs the care up until surgeryand another dentist then takes over the care, the value may be apportionedbetween them. Identify the dentist providing the pre-operative care with thismodifier. The “global fee” is not to be increased, but prorated between thedentists.-99 Multiple Modifiers: By Report
9. FAILURE OF PATIENT TO KEEP A SCHEDULED APPOINTMENT:
In the event a patient fails to keep ascheduled appointment, the health care provider is not to bill for any services that would have beenprovided by said appointment nor shall there be any reimbursement for such scheduled services (i.e.,reimbursement for a “no show” appointment is not allowed). This rule does not apply with regard to adeposition, testimony, or IME.
10. COST CONTAINMENT:
Nothing in this section shall preclude an employer (or insurance carrier) fromentering into payment agreements to promote the continuity of care and the reduction of health carecosts. Such payment agreements, if less, will supersede the limitation amounts specified herein. Pleaserefer to K.S.A. 44-510i(e) for further clarification, if necessary.
CONVERSION FACTOR = $35.75
DENTISTRY
(CONVERSION FACTOR = $35.75)CODEUNIT VALUECODEUNIT VALUECODEUNIT VALUE
D0120 0.76 D1205 1.67 D2752 17.98D0140 0.98 D1310 BR D2780 BRD0150 1.10 D1320 0.30 D2781 BRD0160 1.45 D1330 0.67 D2782 BRD0170 BR D1351 0.83 D2783 BRD0180 BR D1510 5.26 D2790 18.39D0210 2.24 D1515 7.41 D2791 13.83D0220 0.43 D1520 4.00 D2792 14.54D0230 0.35 D1525 6.00 D2794 BRD0240 0.60 D1550 0.93 D2799 BRD0250 1.00 D2140 1.96 D2910 1.30D0260 0.50 D2150 2.48 D2915 BRD0270 0.43 D2160 3.01 D2920 1.55D0272 0.70 D2161 3.60 D2930 4.39D0274 1.00 D2330 2.41 D2931 5.31D0277 BR D2331 3.06 D2932 BRD0290 BR D2332 3.75 D2933 BRD0310 BR D2335 4.46 D2934 BRD0320 BR D2390 BR D2940 1.61D0321 BR D2391 BR D2950 4.34D0322 BR D2392 BR D2951 0.53D0330 1.91 D2393 BR D2952 6.34D0340 2.00 D2394 BR D2953 BRD0350 BR D2410 BR D2954 5.00D0415 BR D2420 BR D2955 BRD0416 BR D2430 BR D2957 BRD0421 BR D2510 12.53 D2960 8.65D0425 BR D2520 14.33 D2961 BRD0431 BR D2530 BR D2962 16.81D0460 0.73 D2542 BR D2971 BRD0470 1.52 D2543 17.07 D2975 BRD0472 BR D2544 16.67 D2980 BRD0473 BR D2610 14.30 D2999 BRD0474 BR D2620 15.95 D3110 1.36D0475 BR D2630 17.00 D3120 1.29D0476 BR D2642 17.35 D3220 2.77D0477 BR D2643 18.21 D3221 BRD0478 BR D2644 18.50 D3230 3.12D0479 BR D2650 12.40 D3240 3.19D0480 BR D2651 14.17 D3310 10.83D0481 BR D2652 17.00 D3320 12.93D0482 BR D2662 13.00 D3330 16.06D0483 BR D2663 15.77 D3331 BRD0484 BR D2664 17.00 D3332 BRD0485 BR D2710 11.90 D3333 BRD0502 BR D2712 BR D3346 BRD0999 BR D2720 17.37 D3347 BRD1110 1.50 D2721 BR D3348 BRD1120 1.07 D2722 BR D3351 BRD1201 1.33 D2740 19.67 D3352 BRD1203 0.64 D2750 19.17 D3353 BRD1204 0.69 D2751 17.22 D3410 9.37
Current Dental Terminology
copyright 2002, 2004 American Dental Association. All rights reserved.
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Department of Labor: 16KWCMedicalFeeSchedule2005-Dentistry
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