OAR 410-123-1620: Coding and Documentation

(1) Providers must use the standardized code sets adopted by the Health Insurance Portability and Accountability Act (HIPAA) and the Centers for Medicare and Medicaid Services (CMS), and by the Chapter 410 Division 120 rules. (2) Unless otherwise directed in this Chapter 410, Division 123 rule, providers must accurately code claims according to the national standards in effect for the date the service(s) was provided. National Code Set issuance alone may not be construed as coverage or a covered service by the Authority. (3) The Authority or designee may review or audit providers’ claims before or after payment in accordance with OARs 410-120-1396, 410-120-1395, or 410-120-1397 and payments may be denied or subject to recovery if the review or audit determines the care, service or item; (a) Was not provided in accordance with this Chapter 410 Division 123, or Chapter 410 Division 120 rules; or (b) Does not meet the criteria for quality or appropriateness of payment. (4) Procedure codes: (a) For dental services, and procedures that are directly related to the teeth and the structures supporting the teeth, use Current Dental Terminology (CDT) codes as maintained and distributed by the American Dental Association (ADA). Contact the ADA to obtain a current copy of the CDT reference manual; (b) For physician provided oral health services performed due to an underlying medical condition (i.e., procedures on or in preparation for treatment of the jaw, tongue, cheek, roof of mouth), use Health Care Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes; and (c) For procedures covered under the Authority’s medical surgical program, refer to Chapter 410, Division 130. (5) International Classification of Diseases 10th Clinical Modification (ICD-10-CM) diagnosis codes are: (a) Not required for dental services submitted on an ADA claim form; and (b) Are required for medical surgical program services submitted on a professional claim form (refer to Chapter 410, Division 130). (6) Ancillary services must be medically necessary and dentally appropriate: (a) For medication and deep sedation provided in hospitalization, conditions must be above the funding line of the Prioritized List and are subject to the Prioritized List’s ancillary guideline notes; (b) Some ancillary codes are not eligible for separate reimbursement (Refer to OAR 410-123-1260); and (c) Ancillary codes covered by Medicaid are listed in Code Group 6060 and can be found by referencing data.oregon.gov/Health-Human-Services/Group-6060-Ancillary-Services/fq2m-i6ix/about_data. (7) Records and documentation: (a) To be eligible for reimbursement, providers must comply with all dental services rules, criteria, billing, and limits in this Chapter 410 Division 123 and Chapter 410 Division 120 and shall maintain records that fully support the extent of the service(s) and all procedure codes for which payment is requested; (b) Providers must maintain clinical, financial and other records, capable of being audited or reviewed, as required under Chapter 410 Division 120 and Chapter 410 Division 141; (c) Providers must keep records for seven (7) years. Providers contracted with a CCO must meet the record retention requirements in OAR 410-141-3520; and (d) Providers must have in each client’s medical record a detailed description of the clinical indications and dental necessity of the dental service(s), including, but not limited to, the tooth number(s), surface(s), pocket depth(s), and radiographs. The provider must annotate the clinical record each time a service is provided and sign and date the record prior to submitting a claim for payment.