Notification



Notification Issue Date:



Claim Payment Policy


Title:Extraction of Bony Impacted Teeth and Exposure of Impacted Teeth

Policy #:04.00.05d

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

COMMERCIAL MEMBERS

EXTRACTION OF BONY IMPACTED TEETH AND ASSOCIATED SERVICES

The extraction of completely or partially bony impacted teeth is covered and eligible for reimbursement consideration by the Company. However, individual member benefits must be verified because some group contracts exclude coverage for the extraction of bony impacted teeth.

When the extraction of completely or partially bony impacted teeth is covered, the following fees and services performed in association with the extraction are also covered and eligible for reimbursement consideration:
  • The provider procedure fee
  • Appropriate facility charges
  • The evaluation and management (E&M) service
  • The radiographs performed to determine the impacted state

EXPOSURE OF IMPACTED OR UNERUPTED TEETH AND ASSOCIATED SERVICES

The exposure of impacted or unerupted teeth without extraction, by surgery or by other means (e.g., with a device), is not a covered benefit for commercial products of the Company and is, therefore, not eligible for reimbursement consideration.

The following fees and services performed in association with the exposure of impacted or unerupted teeth are also not covered benefits and are, therefore, not eligible for reimbursement consideration:
  • The provider procedure fee
  • Appropriate facility charges
  • The E&M service
  • The radiographs performed to determine the impacted state

MEDICARE ADVANTAGE

The following services and fees are benefit contract exclusions for Medicare Advantage members and, therefore, are noncovered and not eligible for reimbursement consideration:
  • The extraction of completely or partially bony impacted teeth
  • The exposure of impacted or unerupted teeth without extraction, by surgery or by other means (eg, with a device)
  • The following fees and services performed in association with the extraction of completely or partially bony impacted teeth or the exposure of impacted or unerupted teeth without extraction:
    • The provider procedure fee
    • Appropriate facility charges
    • The E&M service
    • The radiographs performed to determine the impacted state

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, records from the physician's office, hospital, nursing home, home health agencies, therapies, other health care professionals, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request.

Guidelines

MEDICARE

Subject to the terms and conditions of the applicable Evidence of Coverage, extraction of bony impacted teeth and exposure of impacted teeth are not covered under the medical benefits of the Company’s Medicare Advantage plans. Therefore, these services are not eligible for reimbursement consideration.

Description

The extraction of bony impacted teeth involves extracting teeth that are either completely or partially covered by bone. Any tooth has the potential to become impacted. However, the most common are the wisdom teeth because they are often the last to emerge, usually between the ages of 17 and 21.

A bony impacted tooth may remain stuck in the bone for various reasons. The area may become overcrowded and prevent the tooth from emerging. The tooth may also become twisted or displaced as it tries to emerge. While impacted teeth may often be painless and cause no apparent trouble, occasionally a partially emerged impacted tooth can trap food, plaque, and other debris causing pericoronitis, a condition associated with inflammation and tenderness around the crown of an impacted tooth.

Impacted teeth may be treated by extraction or exposure. The exposure of impacted teeth involves uncovering unerupted teeth without extraction. Extraction is typically the preferred treatment for an impacted tooth because when the tooth roots of an impacted tooth are allowed to develop, they may wrap around sensitive facial nerves.

References


Centers for Medicare and Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 15: Covered medical and other health services. 150 - Dental services. [CMS Web site]. 10/01/03. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf. Accessed February 4, 2014.

Centers for Medicare and Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 16: General exclusions from coverage. 140 - Dental services exclusion. [CMS Web site]. 10/01/03. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c16.pdf. Accessed Accessed February 4, 2014.

Centers for Medicare and Medicaid Services (CMS). The Carriers Manual. Part 3: Claims process. 2136 - Dental services. [CMS Web site]. 09/08/05. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1725B3.pdf. Accessed February 4, 2014.

Company Benefit Contracts


Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

THE FOLLOWING CODES REPRESENT RADIOLOGIC SERVICES ASSOCIATED WITH THE EXTRACTION OF BONY IMPACTED TEETH

70300, 70310, 70320, 70355


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Diagnosis Code Number(s)

K01.0 Embedded teeth
K01.1 Impacted teeth



HCPCS Level II Code Number(s)



D0220 Intraoral - periapical, first film
D0230 Intraoral - periapical, each additional film
D0330 Panoramic film
D7230 Extraction of impacted tooth - partially bony
D7240 Extraction of impacted tooth - completely bony
D7241 Removal of impacted tooth - completely bony, with unusual surgical complications

THE FOLLOWING CODES REPRESENT NONCOVERED SERVICES FOR ALL INDIVIDUALS:
D7280 Surgical access of an unerupted tooth
D7283 Placement of device to facilitate eruption of impacted tooth


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

Effective 10/05/2017 this policy has been updated to the new policy template
format.
Version Effective Date: 03/26/2014
Version Issued Date: 03/26/2014
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.