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Medical Exams & Imaging

This guide covers billing medical evaluations and imaging (CT, panorex) in Coral — from confirming a medical driver through submitting the claim.

Quick Reference​

RequirementDetails
Prior AuthCT (70486) always requires pre-auth unless true emergency
LMNA physician referral letter can substitute for the LMN in clearance cases
ReferralManaging physician name + NPI required in Box 17/17b
Exam Codes99202–99205 (new patient) / 99212–99215 (established)
Two-Visit RuleGeneral eval (9920x) and specialized eval (9921x) are never billed on the same day
Cancer Screening DxZ12.81 (oral cavity) / Z12.89 (other sites) — pair with 70355 only
warning

No medical reason for the visit = dental claim. Do not bill medical for routine checkups.

Phase 1 — Before Treatment: Verify & Authorize​

1. Confirm there is a medical reason for this visit​

Valid medical drivers:

  • Surgical or medical clearance
  • Systemic disease affecting the mouth
  • Pre- or post-radiation care
  • MRONJ-risk medications
  • Oral cancer screening due to a lesion or specific risk factors (not routine)
Stop

If the patient is here for a routine checkup with no medical driver, this is a dental claim. Do not bill medical.

2. If a physician referred the patient​

Get the physician's referral letter and put it in the chart before the visit. The referral letter can substitute for the LMN — it is gold. Ask their office to fax it ahead of time.

3. If a CT scan is planned​

Get prior authorization first. CT always needs PA unless it is a true emergency.

Stop

Do not take the CT without prior authorization. The scan will not be paid without it.

Phase 2 — At the Visit: Document​

4. Complete a comprehensive evaluation​

The visit must demonstrate medical necessity — document the systemic condition and its relationship to the oral findings.

5. If this is a cancer screening​

Mark the screening lines on the H&N physical evaluation form:

  • Z12.81 — oral cavity cancer screening
  • Z12.89 — other sites

6. Record the patient's time in and out​

The doctor needs total time seated to select the correct E/M level.

7. Write the managing physician's name and NPI in the note​

Example:

"Patient managed by Dr. Jane Smith, NPI 1234567890, for diabetes."

8. For systemic disease cases — include the required sentence​

The note must literally state:

"A direct result of [condition] is … [oral finding]."

This direct-causation language links the systemic condition to the oral finding and is required for payment.

9. Document image interpretation​

"Panorex taken" is not enough. The doctor must write a written reading of what was seen in the note.

Phase 3 — Build the Claim​

10. Diagnosis order on the claim​

Medical diagnosis first:

  1. Driving medical condition (systemic dx, cancer screening dx, etc.)
  2. Supporting oral/tooth-related findings
  3. Cause codes — last if applicable

K-codes (tooth-related) are never listed first.

11. Pick the E/M exam level​

Doctor chooses based on total time or medical decision-making, and documents which method was used:

  • New patient: 99202–99205
  • Established patient: 99212–99215

If anything else was done the same day (x-ray, procedure), add modifier 25 to the exam line.

12. If a screening panorex was taken​

Bill 70355. Pairs only with Z12.81, Z12.89, or Z13.89 when it is a screening film.

13. If the film showed something abnormal​

Add diagnosis R93.0, then:

  • CT of face/jaw: 70486 (must be preauthorized)
  • Follow-up or limited CT: 76380 (not 76100)
  • Image interpretation (if applicable): 76376 / 76377

14. Two-visit rule​

A general evaluation and a specialized evaluation are never billed on the same day. If both are needed, schedule a second visit.

15. One claim per date of service​

Same code repeated = one line with units. List surgical lines highest fee first.

16. Referring physician in Box 17​

Enter the referring physician's name and NPI in Box 17 only if a physician referred the patient.

17. Hold the dental claim​

Wait for the medical EOB before submitting dental as secondary (with EOB attached).

Phase 4 — Submit & Follow Up​

  • If the claim is unpaid at 3 weeks, call the payer.
  • Denied as "not medically necessary"? Appeal it — ~70% of letter appeals succeed. Resubmit with a stronger LMN quoting the payer's own policy.
  • File all call logs, auths, EOBs, and appeals in the chart. Retain for 7 years.
Aftercare visits

Follow-up visits at 91+ days: use Z48.814 (aftercare) + the original diagnosis code.