We often get questions about orthodontics from dental offices. We’ve compiled these answers
to our most frequently asked questions.
1. Do I need to bill separately for an orthodontic workup? Is this a separate fee or part
of the orthodontic treatment?
Whether or not a separate fee is charged for an orthodontic workup or included as part of
the orthodontic treatment is a business decision to be made by the dentist.
2. Does the benefit paid for an orthodontic workup always come out of the orthodontic
maximum?
The benefit payable for an orthodontic workup comes out of the orthodontic maximum
under most patients’ contracts.
3. If a patient comes in for a visit and a panoramic film, and it is determined that the
patient is too young to begin orthodontic treatment, can I charge for the visit and
the panoramic film?
These procedures may be submitted using the appropriate procedure codes of D8660 for
the pre-orthodontic treatment visit and D0330 for the panoramic film. They will be
processed according to the patient’s orthodontic benefit.
4. What code(s) should I use for an orthodontic workup?
An orthodontic workup should be submitted using the appropriate CDT code for each
procedure. The separate fees will be combined under CDT code D8999 and will be
processed according to the patient’s orthodontic benefit, limited to the lesser of the
submitted fees, filed fees, or Delta Dental of New Jersey’s (Delta Dental’s) maximum
allowable charges (MAC) for each of the procedures.
5. How will an orthodontic workup be benefited if I am a general dentist rather than an
orthodontist?
An orthodontic workup is processed according to the patient’s orthodontic benefit whether
performed by a general dentist or an orthodontist.
6. When should I bill for an orthodontic workup?
If billed separately, the fee for an orthodontic workup should be billed when performed.
7. Is a second orthodontic workup covered once Phase I is completed?
Orthodontic workups are processed according to the patient’s orthodontic benefit. Most
plans allow one orthodontic workup for a provider for a full comprehensive orthodontic
treatment plan.
8. What procedure codes should be used when there are multiple phases of
treatment?
Comprehensive orthodontic procedure codes should be used for multiple phase treatment
plans. Each phase is submitted as comprehensive treatment using the code that reflects
the patient’s stage of dentition for that phase (transitional, adolescent or adult). Refer to
the American Dental Association CDT guide or your Delta Dental Participating Dentist
Handbook for more information on stages of dentition and how to code orthodontic
treatment.
9. If treatment is extensive, what procedures should I follow in order that Delta Dental
might consider the extenuating circumstances as part of its reimbursement review?
When submitting claims, any case with extenuating circumstances should be submitted
with documentation for individual consideration.
10. Do I need to send a second claim to receive additional payments? Is this the same
with all Delta Dental plans?
A second claim is necessary only if the patient’s orthodontic benefit is subject to a benefit
year maximum. This is not the majority of cases. Most patients’ orthodontic benefits are
paid according to an automatic payment schedule that does not require a second claim.
The Explanation of Benefits for the initial claim will indicate if remaining benefits will be
automatically generated according to a schedule. This applies to claims processed by
Delta Dental of New Jersey. Other Delta Dental plans may process orthodontic claims
differently.
11. What happens if a patient’s coverage is terminated during treatment?
When coverage terminates during an active orthodontic treatment plan, Delta Dental
prorates its payment. The number of months the patient was not eligible for coverage is
deducted from the total months of treatment. Payment is based on eligible months of
treatment. The payment is calculated by dividing Delta Dental’s maximum liability for the
entire treatment by the total months of treatment and multiplying that amount by the
months of treatment during which the patient was eligible. The result determines Delta
Dental’s orthodontic payment for eligible months of treatment. This amount will be paid
according to the orthodontic payment schedule of the patient’s plan.
12. What information should be listed on the claim form for initial submission of an
orthodontic treatment plan? Where should I list that?
The following information should be provided in the appropriate fields of the claim form or
in the Remarks field if no designated field is provided for the information:
- description of condition / class of malocclusion
- type of appliance
- reason for appliance
- estimated total months of treatment
- date treatment began (if applicable)
- total case fee
- indication of Phase I or Phase II treatment (if multiple phases)
- previous carrier payment information (if applicable)
If clear aligners are being used, indicate this with the amount of additional fee, if
applicable, for aligners over and above your usual fee for conventional treatment.
If Delta Dental is the secondary carrier, provide an explanation of benefits or
statement from the primary plan indicating the total amount to be paid for the
treatment plan being submitted to Delta Dental.
13. If using clear aligners, what is needed for treatment to be considered for payment?
How should it be coded? What additional information is needed?
Treatment plans using clear aligners are processed according to the patient’s contract.
They may be denied, or an optional benefit may be provided for conventional therapy,
subject to all contract limitations and maximums for the conventional therapy. There is no
unique procedure code for clear aligners; use the same procedure codes as for
conventional treatment. Claims need to indicate that clear aligners are being used and
must provide the same information as required for conventional treatment plans. Also,
indicate any additional charges over and above your usual fee for conventional treatment,
if applicable. The additional charges for these procedures are the responsibility of the
patient under most patients’ plans.
14. If the patient is covered by Delta Dental, but the patient has no orthodontic
coverage, do I need to submit a claim form?
Delta Dental participating dentists should submit a claim for all treatment performed on a
Delta Dental patient, whether or not the particular service is covered so that the patient’s
history is complete and so that an Explanation of Benefits can be provided indicating the
patient’s responsibility for the treatment. The patient may need this for circumstances such
as Coordination of Benefits or Flexible Spending Account reimbursement.
15. What happens if a patient has excessive breakage or needs to continually come into
the office? Can I charge an additional fee? Will an additional benefit be payable?
When submitting claims, any case with extenuating circumstances should be submitted
with documentation for individual consideration. This documentation will be reviewed to
determine if an additional benefit is payable according to the patient’s orthodontic benefit
or if the patient should be responsible for additional charges.
16. How do you handle orthodontic pretreatments?
Pre-treatment estimates are recommended for all orthodontic treatment. To request a pretreatment estimate, simply complete and submit an Attending Dentist’s Statement, making
sure to provide all of the information needed for processing an orthodontic treatment plan.
Refer to #12, above.
