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FMX Downgrade

September 24, 2025 by elogan

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FMX Downgrade

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How many x-rays are allowed before insurance will downgrade to FMX? It’s my understanding. You could bill four bitewings and up to six PAs before it will be downgraded. I am being told that anything more than four bite wings and two PAs will be considered FMX. Thanks in advance for Clarification!

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Posted by elogan
Asked on September 24, 2025 5:30 pm
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Depends on the benefit plan but my experience is a total of 14 would be considered FM X
(Anonymous at September 24, 2025 6:18 pm)
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    Hi! It depends on the insurance's rules. Typically, the rule of thumb is that the total sum of the X-rays cannot exceed the cost of the FMX in the insurance's contracted rate. Example: If an FMX is $90 total and the patient is eligible for an FMX, if you billed 4 BWX and 4 PA's and the total exceeded $90, the insurance would pay a total of $90 for all of the x-rays and downgrade it to an FMX (which would now count toward the patient's FMX frequency limitation).

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    Posted by Austinida
    Answered on September 26, 2025 5:00 am
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      It’s best to call the insurance company and ask because all the rules are different and it’s based on the pt insurance plan

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      Posted by Anonymous
      Answered on September 25, 2025 11:53 am
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        Hu! For my experience it's usually 4 PA's and 4 BW

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        Posted by Anonymous
        Answered on September 25, 2025 9:32 am
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          Hi! For my experience it's usually 2 PA's and 4 bw

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          Posted by Anonymous
          Answered on September 25, 2025 9:31 am
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            2BWs-4PAs or 6PAs
            As long as the amount of the combined x-rays do not amount to the charge of an FMX.

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            Posted by Anonymous
            Answered on September 24, 2025 8:36 pm
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              In my experience it really depends on the insurance company. It should be one of the questions you ask when you do insurance verification, because they all
              Have different #’s

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              Posted by Aimed
              Answered on September 24, 2025 6:59 pm
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                This is an interesting problem. FMX is typically 14-20 images. Some insurances consider an FMX at 12 images. Also, multiple PAs and BWX taken on short time frame can be condensed to an FMX. Most often it isn’t the number of images, but rather if the images could cover the full mouth. A child would be far fewer. Or a patient with only 10 teeth left. Typically BWX and 4 PAs makes it thru most plans. But whether it downgrades or not, you code and bill wha you do. Patient pays when responsibility is indicated.

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                Posted by CJ
                Answered on September 24, 2025 6:07 pm
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