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New York State has a separate and unique regulatory approval process for laboratory diagnostic testing. PeriRx is currently in the application process with our SaliMark™ OSCC test and is vigorously committed to pursuing this application approval. 

Insurance Coding Guidelines for the SaliMark™ OSCC Test
For Oral Squamous Cell Carcinoma

Summary of Insurance Guidelines for SaliMark.pages

Introduction

SaliMark™ OSCC is a salivary risk stratification test that detects molecular RNA biomarkers for oral squamous cell carcinoma. The purpose of these guidelines is to identify, to the best of the knowledge of the authors, any related dental and medical benefit coding that might be available for potential reimbursement.

Based on the opinions of coding professionals, services related to patient evaluation and management and the administration of the SaliMark™ test should be predominantly coded under a medical policy. The claims related to office and laboratory services can be submitted by the patient or the practitioner using the forms conveniently provided for you on our website.

Step by Step Instructions for SaliMark™ OSCC Coding Submission

  1. Establish a diagnosis (choose appropriate ICD 10 code)
  2. The laboratory service for the SaliMark™ OSCC test is currently billed under medical insurance
  3. Determine if you want to bill for office services under medical (CPT) or dental (CDT) codes
  4. Determine the level of service that you provided and select the appropriate CPT or CDT code
  5. Either the provider or patient can submit the ADA Dental Claim Form or the CMS 1500 Medical Claim Form

Dental-Medical Necessity

Establishing dental-medical necessity is the basis for successful medical coding, whether the coding takes place in a medical practice or a dental practice. Supporting necessity with ICD 10 is a basic requirement for medical cross coding.


Possible ICD 10 Codes for Diagnosis

checkbox K13.21 Leukoplakia of oral mucosa, including tongue
checkbox K13.4 Granuloma and granuloma-like lesions of oral mucosa
checkbox K13.6 Irritative hyperplasia of oral mucosa
checkbox K13.70 Unspecified lesions of oral mucosa
checkbox K13.79 Other lesions of oral mucosa
checkbox C14.8 Malignant neoplasm of overlapping sites of lip, oral cavity and pharynx
checkbox D37.09 Neoplasm of uncertain behavior of other specified sites of the oral cavity
checkbox Z12.81 Encounter for screening for malignant neoplasm of oral cavity
checkbox Z85.818 Personal history of malignant neoplasm of other sites of lip, oral cavity and pharynx
checkbox Z85.819 Personal history of malignant neoplasm of unspecified site of lip, oral cavity and pharynx

CPT

Related CPT® Codes for Services Rendered

The choice of an appropriate procedure code and diagnosis code is always the sole responsibility of the doctor considering the clinical circumstances of each case. As a result, the possible codes listed should be used only when, in the judgment of the doctor, such codes are appropriate for the case at hand.

 
 

Established Patient Codes

checkbox 99213

Office or other outpatient visits for the evaluation and management of an established patient, which requires at least 2 of these 3 key components:

  1. An expanded problem-focused history
  2. An expanded problem-focused examination
  3. Medical decision making of low complexity

Counseling and coordination of care with other physicians, other qualified healthcare professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family.

 

New Patient Codes

checkbox 99202

Office or other outpatient visits for the evaluation and management of a new patient, which requires these 3 key components:

  1. An expanded problem focused history
  2. An expanded problem focused examination
  3. Straightforward medical decision making

Counseling and/or coordination of care with other physicians, other qualified healthcare professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 20 minutes are spent face-to-face with the patient and/or family.

Note:

If more extensive evaluation is necessary, consider additional CPT codes in the *Addendum located at the bottom of this section.

CDT

CDT Codes for Dental Services Rendered

Though it is the opinion of the authors that the services of the practitioner related to SaliMark™ testing would best be coded under a medical policy, there are CDT dental codes that can be used. In the presence of a lesion suspicious for OSCC (oral squamous cell carcinoma) where additional evaluation is indicated beyond the new patient comprehensive exam or the established patient periodic exam consider:

checkbox D0160 Detailed and extensive oral evaluation – problem focused, by report (excerpt) “a detailed and extensive problem focused evaluation entails extensive diagnostic and cognitive modalities based on the findings of a comprehensive oral evaluation.”
checkbox D0140 Limited oral evaluation – problem focused (excerpt) “an evaluation limited to a specific oral health problem or complaint. This may require interpretation of information acquired through additional diagnostic procedures.”
checkbox D0417 If SaliMark™ testing is indicated, CDT codes for sample collection could be:
Collection and preparation of saliva sample for the laboratory diagnostic testing.
checkbox D9450 Presentation of the SaliMark™ Test Findings:
Case presentation, detailed and extensive treatment planning.
   
 
beakers

Laboratory Codes

The laboratory service related to SaliMark™ testing is billed under separate CPT codes for clinical laboratory services.

checkbox 81599 Is the code for a multi-analyte assay with algorithmic analyses. In the rapidly changing field of molecular pathology testing, it is common for new codes to evolve, and we will update this website with the best available current information.

Final Note & Disclaimer

Codes Are Not Specific To SaliMark™ OSCC Test:
Professionals are obligated to use the most accurate code available based on their professional assessment of a particular case.

Coding and Coverage are NOT the Same:
Accurate coding does guarantee coverage under a particular policy. Third party reimbursement may vary by the payer and the specifics of the patient problem.

All suggestions are samples only and should not be used verbatim. PeriRx has attempted to verify all details of this document but assume no responsibility for omissions, inaccuracies, or errors. We specifically assume no liability, responsibility, or guarantee whatsoever for specific adjudication of a claim, survival of an audit by insurance company or government entity, and acceptability of a narrative or any code reported.


CDT

Addendum: CPT Codes to be Considered When More Extensive Evaluation is Necessary

 

Established Patient Code

checkbox 99214

Office or other outpatient visits for the evaluation and management of an established patient, which requires at least 2 of these 3 key components:

  1. A detailed history
  2. A detailed examination
  3. Medical decision making of moderate complexity

Counseling and/or coordination of care with other physicians, other qualified healthcare professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.

checkbox V99215

Office or other outpatient visits for the evaluation and management of an established patient, which requires at least 2 of these 3 key components:

  1. A comprehensive history
  2. A comprehensive examination
  3. Medical decision making of high complexity

Counseling and/or coordination of care with other physicians, other qualified healthcare professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family.

 

New Patient Code

checkbox 99203

Office or other outpatient visits for the evaluation and management of a new patient, which requires these 3 key components:

  1. A detailed history
  2. A detailed examination
  3. Medical decision making of low complexity

Counseling and/or coordination of care with other physicians, other qualified healthcare professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family.

checkbox 99204

Office or other outpatient visits for the evaluation and management of a new patient, which requires these 3 key components:

  1. A comprehensive history
  2. A comprehensive examination
  3. Medical decision making of moderate complexity

Counseling and/or coordination of care with other physicians, other qualified healthcare professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family.