4.14.07 - Issue # 266 Forward This Newsletter To A Colleague

Carol Tekavec
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Three Insurance Coding Tips

The ADA coding system undergoes revision every two years.  Because of the national Health Insurance Portability and Accountability Act (HIPAA), a mandate exists that requires dentists and insurers to use the most recent version of the ADA code.  Right now this is the Current Dental Terminology-CDT-2007-2008, a copyrighted publication. Those of us who publish guidance and coding manuals must acquire a license to do so from the ADA.  My guidance manual, the Dental Insurance Coding Handbook-2005-2008 is printed under such a license. The current code includes 23 new codes, 33 revised codes and three deletions. 

What follows are three coding tips for common coding problems.

  1. “Difficult” prophys

  2. Coding and billing for “difficult” prophys has always been a problem. Dentists have few choices, none of them completely accurate. There is no designated code for a “difficult” prophy, although D4355-Full Mouth Debridement to Enable Comprehensive Evaluation and Diagnosis is believed by some to apply. However, D4355 is defined as a “gross removal of plaque and calculus that interferes with the ability of the dentist to perform a comprehensive oral evaluation. This preliminary procedure does not preclude the need for additional procedures.” This definition points to the procedure being preliminary in order to facilitate an exam, and makes no mention of “difficulty”. Even so, if the dentist thinks that the patient’s circumstances apply, D4355 may be used. However, it will probably be paid by the dental plan at the D1110-Adult Prophy fee, and it will be after the deductible because it is a Perio Code, not a Diagnostic or Preventive Code. The patient will end up being responsible for a substantial portion of the cost of the service.

    It is possible to use D1110-Adult Prophy with a longer appointment time and a higher fee. The problem with this is that if the dentist is a network provider his/her contract may not allow for a higher fee than has been agreed upon (filed fee) or the plan’s maximum allowable benefit. Plus the dentist may not be able to charge the patient the difference as per his/her contract agreement. If this is the case, the dentist has another choice; charge out the D1110 at the “normal” fee, and include D4999-Unspecified Periodontal Procedure, by Report on the claim form with the additional charge. A narrative explaining why the additional time and procedures were required should be listed in section #35 of the claim form. The claim will likely be delayed for a consultant to review the case, and the D4999 will likely still be denied, however, the network dentist may then charge the patient the difference. He/she does not have to absorb the cost.

    The simplest way may be to schedule the patient for two appointments under code D1110-Adult Prophy. The network dentist charges the “normal” fee for each visit. The first D1110 will likely be covered by the plan. If the plan requires six months and one day to pass between D1110 appointments, the second D1110 will likely not be paid by the plan, however, the dentist may bill the patient. The patient’s next D1110 in six months will still be covered. This method is also the easiest to explain. Patients can understand that more time is necessary and that two visits are required.

    If patients need more than a “difficult” prophy, or are undergoing scaling and root planing, a brochure explaining the differences is most helpful. Go here to see brochure “What is the difference between a “cleaning”, a root planing, and periodontal maintenance”

  1. Coding exams
    There are seven codes describing exams or “clinical oral evaluations”. All evaluation codes are equally valid for dentists to report. A dentist should perform and report whichever evaluation code he/she decides is appropriate; and bill accordingly. For payment, however, most carriers follow an industry guideline. That is; any comprehensive evaluation, such as a D0150-Comprehensive Oral Evaluation-New or Established Patient, or D0180-Comprehensive Periodontal Evaluation-New or Established Patient, will be covered once every 3 to 5 years. If it is reported more frequently, the fee for a D0120-Periodic Evaluation is typically paid. Most carriers pay for a D0120 twice annually.

  2. How does an office get “veneers” paid for by insurance?
    As most dentists and staff know, cosmetic treatments are frequently denied by dental plans. However, a few plans offer a “lifetime” maximum benefit for certain conditions such as enamel hypoplasia, and pegged laterals. Plans will likely cover anterior veneers that are required for decay, to replace existing defective restorations (2-5 years old), and to restore open or decayed margins of existing restorations, crowns, or veneers. Rather than giving up on helping a patient receive reimbursement for a veneer, supply the insurance carrier with a detailed narrative, radiographs, if appropriate, and photographs to explain and illustrate recommended treatment. Don’t wait for the carrier to ask for “more information”. Supply all the information that you can with the initial claim.

Dealing with dental insurance can be a challenge.  However, patients who have insurance have more treatment and more complete treatment than those without.  Helping patients with their insurance plans can be a practice builder.

Carol Tekavec CDA RDH is the president of Stepping Stones to Success, and a nationally known author and lecturer.  She is a consultant to the ADA Council on Dental Practice and a practicing dental hygienist.  She may be contacted at www.steppingstonestosuccess.com or 800-548-2164,




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