BASIC (09-06)

DDSs may elect to use the Medicare fee schedule as the benchmark for establishing the maximum rates of payment. Medicare uses the AMA CPT coding system.

A. Procedure

DDSs should crosswalk items in the State fee schedule to the CPT (see DI 39545.675, DDS Guide to Establishing a Fee Schedule Using Medicare Fees). Crosswalk refers to the process of converting the DDS code for a service or procedure to the Medicare code for the same or similar type of service or procedure.

NOTE: DDSs may use the same CPT codes to relate its fee schedule to the Medicare fee schedule. However, DDSs may need to establish another coding convention to differentiate these exams on their internal case processing system.

B. Description of CPT codebook

A thorough review of the Introduction and the guidelines at the beginning of each of the six major sections of the CPT book is necessary to understand the coding and naming conventions.

• CPT lists the terms and codes for reporting services and procedures performed by physicians.

• Appendix B contains code changes, deletions and additions.

• Each procedure/service is identified with a 5-digit code. CPT codes are divided into six major categories: Evaluation and Management (E/M), Anesthesiology, Surgery, Radiology, Pathology/Laboratory, and Medicine. These codes may be further defined by starred (*) designations for certain minor surgical procedures, and by modifiers to help explain an unusual circumstance associated with a service or procedure.

C. Procedure – guidelines for using certain CPT sections

1. Laboratory work

Some States reimburse separately for specimen collection (code 36415).

2. X-rays

States may reimburse some providers separately for the technical and professional components of an x-ray fee. The CPT includes “modifier codes” to distinguish the procedures in Appendix A (e.g., add the modifier “–026” to the professional component.)

The Medicare fee schedule provides a breakout for technical, professional and combined/composite fees for x-rays. The combined fee is less than the technical fee plus the professional fee.

3. Examinations

The CPT describes many different levels of exams. DDSs should select the code that most closely matches the complexity of the exam being ordered. For example, the DDS might choose to use CPT code 99243 for most of their exams. However, if the DDS orders less comprehensive exams (e.g., limited or brief), locate an exam in one of these sections with a description and lower level of decision making to match the exam, such as 99241. Less comprehensive exams have lower Medicare fees.

If a particular exam requires more extensive decision making and documentation (e.g., Neurological or Orthopedic), consider using a higher level of exam which relates to a higher Medicare fee, such as 99244.

DDSs sometimes “bundle” ancillary tests with exams and order the entire package. DDSs should maintain a crosswalk between the individual components of these packaged examinations to the Medicare fee schedule. The package price should not exceed the sum of the Medicare fees for the individual parts (e.g., a cardiological packaged exam could include an examination, a chest x-ray, and a treadmill test).

NOTE: Medicare assigns different fees to each level of exam depending upon the complexity of the exam and the medical decision making.

The “Evaluation and Management Services Guidelines” section in the CPT provides guidance in selecting the appropriate level of service for each exam requested by the DDS. The codes listed in the “Consultation” and “Office or Other Outpatient Services” sections of the CPT are recommended.

4. Mental examinations and psychological testing

The following coding options are recommended for mental status exams.

DDSs find it difficult to relate Psychological Testing to CPT codes because they are not listed separately in the CPT book. CPT code 96101 for Psychological Testing is recommended. For this code, Medicare pays an hourly rate fee.

EXAMPLE: To establish the maximum fee rate using the code 96101, DDS would:

1. Determine the amount of time that it takes to administer each test.

2. Use the Medicare fee for 96101 multiplied by the number of hours to administer each test to determine the maximum fee payable for each test. For example: Medicare fee for code 96101 is $62 per hour, the maximum fee for the Wechsler Intelligence Scales for Children would be: $62 x 1.25 hours or $77.50.