Billing for Prosthesis Designed and Prepared by the Dentist

December 6th, 2016 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Categories:   Billing   Dental   CPT® Coding  
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For maxillofacial services, if a prosthesis is provided, and is designed and prepared by the dentist, the Medicare Part B carrier may be billed with CPT codes 21076 through 21089. If the prosthesis is prepared by an outside laboratory, the laboratory bill goes to the Durable Medical Equipment Regional Carrier (DMERC), with Level II HCPCS codes. That outside laboratory charge and payment should be supplied in Item 19 of the CMS-1500 form, or the electronic equivalent. Medicare Part B then pays through CPT code 21299

If there is "revision," "relining," "adjustment to prosthesis," etc., the procedure components should be adequately described, and the time interval since fabrication, or previous modification, should be included in the documentation. Since an unlisted code is often used, the descriptive documentation is necessary. 

Under Medicare policy, care, treatment, removal, replacement of teeth or structures directly supporting the teeth are not covered. Extraction of teeth to prepare the jaw for radiation treatment of a neoplastic disease can be covered. If a service, otherwise non-covered, is an integral part of a covered procedure, e.g., associated with the surgical removal of a tumor (for other than dental purpose), it can be covered. X-rays related to a covered procedure can be covered.

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