In this example Imagn Billing case you will see how a dental office in North Carolina successfully billed for an endosteal implant. Our Imagn Billing team processed this claim on 08/13/2020 to BCBS of NC insurance and it was paid on 09/17/2020.
The 61-year-old male patient presented for an emergency appointment with symptoms of pain levels higher in the evening and non-reactive to medication. Radiographs showed radiolucency surrounding tooth 29 with significant caries lesions. The patient agreed that an endosteal implant would be the best course of treatment to maintain bone in the mandible.
Proving Medical Necessity
The active infection along with the caries lesion makes this procedure urgent and medically necessary. The abscess has already started to deteriorate the bone, causing atrophy. Failure to remove the tooth, which is the source of the infection, could result in numerous health outcomes along with irreversible bone atrophy. The only treatment option, to prevent further atrophy and restore function is an extraction, implant placement, and final restoration with abutment and crown.
Example Clinical Note
John Doe DOB – 2/12/1958
Clinical Assessment 1/10/2020: Emergency Visit
S: Patient has been experiencing pain with the highest level of 7 mostly at night with a level of 4 during the day. It has affected his sleep to the point of not being able to rest even using over the counter Anbesol anesthetic and ibuprofen 1000mg for the last 3 nights.
O: Radiographs taken today with radiolucency and infection surrounding and through mandible in the area of 29.
BP 130/90 P 88
Health review: Medication review:
Dry Mouth Prescription Omeprazole
Intraoral: Erosion due to GERD with added Xerostomia from long term use of Lisinopril which also explains the inflammation.
Dr reviewed procedure with patient and results of x-rays w/ patient.
Medical Indication for removal of 29:
extensive decay dx clinically with infection and caries lesions. Gave patient options and wanted to proceed with implant.
Medical Indication for BG: Prepare site for future implant placement, maintain healthy bone level to support existing dentition.
Medical Indications for Membrane: protect bone graft and allow bone to mature uninterrupted.
3.Implant abutment and crown
Reviewed effects of bone and soft tissue loss after extracting the tooth/teeth and the need for socket preservation grafting to help prevent bone and soft tissue loss.
Reviewed and signed:
Dr. Sarah Smith
Billing Medical Insurance
The practice collected all required documentation and clinical SOAP notes. After completing the verification of benefits, it was determined that coverage was available after the deductible is satisfied. Pre-Authorization was required and was completed with approval along with a Gap exception.
Without medical insurance contribution, the practice would be writing off approximately 32% and using almost half of an annual $2000.00 maximum. Medical insurance saved the patient and the practice approximately $1500, whereas dental insurance would be almost exhausted. The patient also completely satisfied their deductible, so moving forward they will have less out of pocket expenses if a healthcare issue arises.