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COVID-19 Coding and Billing Interim Guidance : PPE

If you are a participating provider : it depends . Dentists who have signed participating provider agreements have a contractual relationship with their third party carrier . These agreements determine policies that the dentist has agreed to accept . Refer to the EOB or another communication from a third party payer to determine ( 1 ) whether the patient can be billed ( i . e . denied versus disallowed / non-billable ) and ( 2 ) by how much .

If the payer does not pay your full fee , then some scenarios that may occur are as follows :

• Payer may apply a maximum allowable charge and decide to cover only a portion of that amount leaving the remaining as the patient ’ s responsibility . You can then bill the patient up to the maximum allowable charge .

• Payer may deny the claim as a non-covered service . Denied claims are typically billable to the patient but :

• In states without non-covered services laws the dentist may still be obligated to only charge the maximum allowed fee as determined by the payer .

• In states with non-covered services laws the dentist may be able to charge the patient up to his / her full fee . Ensure you are following your state laws on non-covered services .

• Payer may bundle the fee with the payment for other procedures provided during the same visit and disallow or make any other charges non-billable to the patient . If charges are disallowed or noted as non-billable to the patient on the EOB , the patient may not be charged a separate fee for the PPE .

ADA is actively advocating on this issue . We will update the information in this guide as more information becomes available . For Medicaid patients , please check with your state Medicaid agency . Inform the patients prior to the visit on any changes to your charges or financial policy .

Can I charge only my uninsured patients for increased PPE costs ?

It is unethical to only charge uninsured patients or only seek reimbursement for insured patients to address the costs of PPE . See Section 5 . B . ( Representation of Fees ) of the ADA Principles of Ethics and Code of Professional Conduct . See in particular Advisory Opinion 5 . B . 3 . ( Fee Differential ).

I heard that payment may be delayed because I reported a D1999 code ?

In general , a “ by report ” code may prevent auto-adjudication of claims . Manual review is typically required to process codes with accompanying remarks resulting in a delay in processing payments . The ADA has been informed by third party payers that while some carriers are able to process claims efficiently with the increased use of D1999 , other payer systems are experiencing some delays .

Has the Centers for Medicare & Medicaid Services ( CMS ) released any guidance around PPE payments ? Thus far CMS has issued the following Q & A :

“ During the public health emergency , some providers are experiencing significant cost increases . Without knowing how much costs will increase right now , how should states approach making adjustments to Medicaid payment rates and methodologies to ensure that Medicaid costs are paid during the public health emergency period ?

States have flexibility to make reasonable adjustments to Medicaid payments to better align Medicaid payments with the increased cost of providing services to Medicaid beneficiaries during the PHE under the