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Emergency & Trauma

This guide covers billing emergency and trauma-related dental care in Coral — including the 72-hour emergency window, coordination of benefits with auto/workers' comp carriers, and the phased LMN for follow-up care.

Quick Reference​

RequirementDetails
Prior AuthNo PA within 72-hour emergency window (Box 24C = Y). Elective repair after 72 hrs requires PA + LMN.
LMNRequired for follow-up/elective care: phased plan + future-treatment reservation paragraph
COB OrderAuto/PIP or workers' comp → medical → dental
Primary DxS-codes (injury) first, 7th character A/D/S; external cause code last
Box 24CMark "Y" for emergency visits within 72 hours
info

I&D for an abscess (K12.2) almost never requires prior auth, even outside the emergency window.

Phase 1 — Before Treatment: Verify & Authorize​

1. Have the patient complete the Trauma Form​

Every field must be filled in by the patient in their own words. The form must capture:

  • Incident date
  • Incident location
  • How it happened (mechanism)
  • What was injured
  • Is this work-related? Auto accident? Other?
Stop

Do not build this claim until every field is filled in. Missing accident details = automatic denial.

2. Identify the primary payer​

Accident TypePrimary Payer
Work-relatedWorkers' comp — get the claim # and adjuster name/phone before treating
Auto accidentAuto/PIP policy — get the claim # and the state where the accident happened
OtherMedical insurance

3. Check the 72-hour clock​

  • Within 72 hours: This is an emergency. Skip prior auth. Mark Box 24C "Y" on the claim.
  • After 72 hours: Elective repair requires prior auth + LMN before treatment.
Stop

More than 72 hours have passed and this is the elective repair phase with no prior auth? Get the PA and LMN approved before doing crowns, implants, or elective work.

4. If LMN is required, make it do three things​

  1. Lay out the phased treatment plan
  2. Include the future-treatment reservation paragraph (preserves the right to treat later complications)
  3. If treatment extends past the accident year + 1, state why

Phase 2 — At the Visit: Document​

5. Document each injured tooth separately​

Note whether each fracture is open (pulp/dentin exposed) or closed — this changes the S-code.

6. Include the pre-injury status sentence​

Write exactly:

"Teeth were previously healthy, decay-free, in good repair, and firmly attached."

7. Take photos AND x-rays — and interpret both​

Document that images were taken AND read, with a written interpretation of findings in the note.

8. Record any prior ER or hospital care​

Include: facility name, date, and what was done.

Phase 3 — Build the Claim​

9. Diagnosis order on the claim​

  1. S-codes (injury) — first
    • 7th character: A = first visit for this injury, D = follow-up, S = sequela/late effects
    • Sequela = 3-code structure: S-code (7th char S) + current condition + external cause
  2. K-codes — never first
  3. External cause codes (W/V) — always last

10. Pick the E/M level​

Doctor chooses by total time or medical decision-making, and notes which method in the chart (99202–99215).

11. One claim per date of service​

Same code repeated = one line with units, not multiple lines. List surgical lines highest fee first.

12. Complete the trauma-specific claim boxes​

BoxWhat Goes Here
Box 10a–cCheck the correct accident type (employment / auto / other) + state for auto
Box 11bProperty/casualty claim # (qualifier Y4) if workers' comp or auto
Box 14Injury date with qualifier 431 (onset) or 439 (accident)
Box 24C"Y" if emergency within 72 hours

13. Attach the LMN reference number (if applicable)​

Phase 4 — Submit & Follow Up​

Bill in the correct COB order​

  1. Liability / workers' comp / auto carrier first
  2. Health plan second — attach the first EOB
  3. Dental last — attach all prior EOBs

File fast​

Trauma claims have short timely-filing windows with WC and auto carriers. Submit the same week, not next month.

  • If the claim is unpaid at 3 weeks, call the payer.
  • Denied as "not medically necessary"? Appeal it — ~70% of letter appeals succeed.
  • File all call logs, auths, EOBs, and appeals in the chart. Retain for 7 years.