Covered and Noncovered Services : Oral and Maxillofacial Surgery

An Overview

BadgerCare Plus's coverage of oral and maxillofacial surgical services is limited to services provided due to trauma or congenital malformations, such as clefts, or the removal or pathologic, painful, or non-restorable teeth. Corrective congenital surgery and orthognathic surgery are limited to specific cases due to severe handicapping malocclusions.

Wisconsin Medicaid reimburses for the following oral and maxillofacial surgery services:

• Extractions
• Surgical extractions
• Alveoloplasty
• Surgical excision of soft tissue lesions
• Surgical excision of intra-osseous lesions
• Excision of bone tissue
• Surgical incision
• Treatment of simple and compound fractures
• Reduction of dislocation and management of other temporomandibular joint dysfunctions
• Repair of traumatic wounds
• Complicated suturing
• Other surgical and repair procedures

Providers are required to obtain PA for certain specified oral and maxillofacial surgery services before delivery of the service, unless the service is performed on an emergency basis. BadgerCare Plus may request a diagnostic cast or oral/facial photographic images to aid in evaluating any PA request.

BadgerCare Plus has identified allowable oral and maxillofacial surgery procedure codes.

Assistant Surgeon

An assisting surgeon is allowed for some allowable complex surgery procedures.

When CPT billing providers request reimbursement for an assisting surgeon, indicate modifier 80 (Assistant surgeon) in the appropriate element on the claim. If a procedure requires PA and an assistant surgeon will be involved with performing the procedure(s), providers are required to request PA for both on the same PA request.

ADA billing providers are required to request PA for assisting surgeons. Providers should use D7899 for an assistant surgeon for TMJ services and D7999 for all other types of assisting surgeon services.

Claims Submission Options

Dentists are assigned a procedure coding system to use for submitting claims for oral surgery services based on their specialty.

Assignment of Oral Surgery Claims Submission Method

Assignment of a provider's oral surgery claims submission method depends on the dental specialty chosen during Medicaid enrollment. This assignment is necessary because it enables BadgerCare Plus to identify the oral surgery procedure codes a provider may use to ensure accurate reimbursement.

Identical Policies and Reimbursement for All Dentists

All dentists, regardless of specialty:

• Receive the same reimbursement for the same procedures.
• Have virtually the same program limitations, such as PA requirements, for the same procedures.
• Submit claims for all other dental (nonsurgical) procedures using CDT procedure codes and a few BadgerCare Plus HCPCS procedure codes.
• Submit claims for all oral surgeries using the code system assigned at enrollment.
• Cannot temporarily alternate between coding systems, using different procedure codes on different days.
• Find that the CPT claims submission method requires fewer attachments and is easier to submit electronically.

Decreased Attachments and Claim Processing Time

The CPT coding system is more precise than the ADA coding system for describing the same oral surgery procedures. Therefore, most CPT codes do not require operative and pathology reports for manual pricing by Wisconsin Medicaid, as well as the additional time needed for processing manually priced claims. This facilitates electronic claims submission.

Excision of Hyperplastic Tissue

For ForwardHealth coverage of PA requests for the excision of hyperplastic tissue (per arch), the member must have an edentulous ridge, and have difficulty wearing a prosthesis. The member must have adequate healing after tooth extraction before requesting this service. The service includes all local anesthetic, suturing, postoperative care, and soft tissue conditioning of any appliances at the time of surgery.

Frenulectomy Procedures

Frenulectomy procedures involve the surgical removal or release of mucosal and muscle elements of a frenum associated with a pathological condition or interference with proper oral development or treatment.

ForwardHealth covers frenulectomy procedures without PA.

Members must meet one of these criteria:

• The member's frenum creates a central incisor diastema.
• The member's frenum creates ankyloglossia.
• The member's frenum creates periodontal defects.
• The member's frenum requires removal to complete orthodontic services.
• The member's frenum interferes with denture stabilization, due to its high attachment on the ridge.

Note: An image of the obstructed frenum is not required to be submitted with claims, but must be available in the medical or dental record. A dentist statement regarding the medical/dental need for the treatment is required to be available upon request.

Allowable Procedure Codes for Frenulectomy

Providers are required to indicate frenulectomy procedures using one of these CDT codes as applicable:

• D7961 (Buccal/labial frenectomy [frenulectomy])
• D7962 (Lingual frenectomy [frenulectomy])

These billing rules apply to the coverage of frenulectomy procedures when billed under CDT codes D7961 or D7962:

• Covered areas of the oral cavity for frenulectomy procedures are 01 (maxillary arch) and 02 (mandibular arch). The area of the oral cavity is required to be indicated on the claim.
• Up to two units of service per area of the oral cavity are allowed per DOS. A total of four units are allowed per DOS.
• CDT codes D7961 and D7962 are defined as separate procedures, meaning that CDT codes D7961 and D7962 should not be separately billed when the frenulectomy is rendered in conjunction with any other surgical procedure in the same surgical area, by the same provider.

Allowable Procedure Codes for Oral Surgeons

Oral surgeons are required to indicate either CDT code D7960 or one of these appropriate CPT codes:

Limitations

Many oral surgeries are limited to once per day. This limitation may be exceeded if narrative on the claim form demonstrates the additional services were medically necessary.

Osteoplasty/Osteotomy

Wisconsin Medicaid reimburses for osteoplasty/osteotomy for orthognathic deformities for only the most severe orthodontic skeletal malocclusion. Criteria for PA request approval for osteoplasty or osteotomy includes one of the following, where the procedure is necessary to correct:

• The most severe cases of protruding or retruding mandible or maxillae where conventional orthodontics cannot provide a stable and acceptable outcome
• The most severe cases of open bite where conventional orthodontics cannot provide a stable and acceptable outcome
• A significant skeletal malocclusion where conventional orthodontics cannot provide a stable and acceptable outcome
• Severe malocclusions caused by disease or injury where conventional orthodontics cannot provide a stable and acceptable outcome

If the deformity has been caused by disease or injury, a physician's statement is required.

The criteria for PA request approval for osteoplasty/osteotomy include one of the following:

• A frenum that creates a central incisor diastema
• Ankyloglossia
• Periodontal defects
• The necessity of osteoplasty/osteotomy to complete orthodontic services

Pre- and Post-Care Days

Reimbursement for procedures directly related to an oral surgery is incorporated into the reimbursement for the oral surgery procedure.

Palliative treatment, application of desensitizing medicaments, and other related procedures are not allowed at least three days before and 10 or more days after the surgery. Claims for other procedures directly related to the surgery must not be submitted separately, regardless of when the claim for the procedure is submitted.

If the procedure is not directly related to oral surgery, the limitation can be overridden with a narrative demonstrating that fact on the claim form. For example, a procedure may be performed on a separate section of the mouth than the oral surgery.

Removal of Extosis Maxillae or Mandible

Criteria for PA approval for the removal of extosis maxillae or mandible includes one of the following situations:

• The exostosis presents an undesirable undercut.
• The exostosis presents problems with insertion or stability of the prosthesis.
• The removal is medically necessary due to the presence of pain caused by the insertion or wearing of a removable prosthesis.

Removal of a Foreign Body

PA requests for removal of a foreign body must be accompanied by one periapical radiograph.

Replantation and Splinting

BadgerCare Plus's coverage of the replantation and splinting of a traumatically avulsed or subluxated tooth:

• Includes the postoperative follow-up
• Includes the removal of any splints and wires
• Does not include any root canal therapy for the involved teeth

Surgical Exposure of Impacted or Unerupted Tooth

Coverage of the surgical exposure of an impacted or unerupted tooth for orthodontic reasons includes placement of any orthodontic appliance on the impacted tooth, such as any hooks, wires, and pins to aid eruption through orthodontics.

Clinical notes and an operative report must be retained in the member's medical or dental record.

Surgical Exposure of a Tooth to Aid Eruption

For surgical exposure of a tooth to aid eruption, the tooth must be impacted by an adjacent tooth, and not close to natural eruption. This service can be requested for primary and permanent teeth.

This service does not include placement of any hooks, wires, pins, etc., to aid eruption through orthodontics.

Surgical Extraction of a Tooth

Wisconsin Medicaid's reimbursement for surgical extraction of a tooth is limited to when an extraction is necessary for the following reasons:

• An emergency, which is a situation when an immediate service must be provided to relieve the member from pain, an acute infection, swelling, fever, or trauma
• Orthodontia (for children up to age 21)

If during the routine extraction of any tooth the extraction unexpectedly becomes a surgical extraction, the surgical extraction is considered a dental emergency. The provider should indicate that the procedure was an emergency when submitting a claim to ForwardHealth. Providers should also retain documentation of the circumstances of the procedure in the member's records.

Suturing

Wisconsin Medicaid reimburses providers for suturing only when it is provided as a result of trauma. Suturing is not separately reimbursable when it is part of a surgical procedure, as suturing is included in the surgical procedure and fee.

When submitting claims for suturing, include an operative report describing the procedure, complexity of closure, location of laceration, and length of laceration(s) repaired.

Temporomandibular Joint Surgery

The TMJ office visit requires detailed and extensive examination and documentation of the member's TMJ dysfunction.

A TMJ office visit consists of:

• A comprehensive history
• Clinical examination
• Diagnosis
• Treatment planning

Initial Treatment

The initial treatment of a TMJ dysfunction must consist of nonsurgical treatments which include:

• Short-term medication
• Home therapy (for example, soft diet)
• Splint therapy
• Physical therapy, including correction of myofunctional habits
• Relaxation or stress management techniques
• Psychological evaluation or counseling

Nonsurgical TMJ treatments are not covered.

Prior Authorization

Providers are required to include appropriate current clinical physical and dental information about the member on the PA request to enable ForwardHealth to determine whether the surgery is medically necessary. Only TMJ surgeries with favorable prognosis for surgery are considered for approval.

TMJ Surgery Procedures and Managed Care Programs

State-contracted MCOs may designate the facility at which the TMJ surgery is performed. The MCO is responsible for paying the cost of the surgery and all related services (for example, hospitalization and anesthesiology).

Wisconsin Medicaid does not reimburse for a TMJ surgery performed by a dentist on a fee-for-service basis when provided to a member enrolled in an MCO that covers dentistry. Therefore, to obtain reimbursement, dentists must participate in or obtain a referral from the member's MCO since the MCO is responsible for paying the cost of all services. Failing to obtain an MCO referral may result in a denial of payment for services by the MCO.

If the MCO does not cover dental services, the dentist may submit a PA request to ForwardHealth and, if approved, the dental surgeon is reimbursed for the evaluation on a fee-for-service basis.

• ForwardHealth has identified MCOs and services for which dental providers may request fee-for-service reimbursement.
• If PA is obtained, the MCO is responsible for paying the cost of all related medical and hospital services and may therefore designate the facility at which the surgery is performed.
• The dentist must work closely with the MCO to assure continuity of coverage.