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  05.12.05 Issue #166


Insurance and Radiographs

Tom Limoli, Jr.

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Look Beyond What Can Be Seen – It just might surprise you...

Much has already been written concerning Evidenced Based Dentistry and its associated Parameters of Care. For those just now returning from Mars – evidence based parameters of care is nothing more than the scientific analysis of when you do what you do as compared to how you do it if you actually do anything? Or to put it simply - are we doing the appropriate treatment at the appropriate sequential time for the specific needs of an individual patient.

Parameters of care are very different and many say should not be confused with or influenced by a benefit plans parameter of payment . This two lane road moves in both directions as parameters of payment should not govern or direct parameters of care.


A benefit plans parameter of payment is guided primarily by the strength of the plan purchasers' almighty dollar. The more one pays for a plan – the richer the benefits available to the enrollees. High dollar plans have high dollar benefits. Conversely, low dollar plans don't have a whole lot of covered benefits. One might benefit prophylaxis every six months while the other acknowledges the procedure one, two or three times a benefit year.

So which plan actually costs more? Which plan has the overall greater benefit to the patient? Are the two actually one in the same ? Are higher preventive benefits actually reducing the need for more costly restorative, periodontal and/or surgical therapies? These are the questions asked by plan purchasers as well as dental researchers.

This quagmire is more accurately brought to light than with the simple irradiation of a few bitewing films.

The patients benefit plan may say: “Bitewing radiographs are reimbursed twice in a calendar year.” To most dental offices this means: “Take bitewings every six months when the patient comes in for a prophy.” Many offices, following this thinking, have been audited and asked to refund thousands of dollars previously reimbursed for these radiographs. Why? Because there was no documentation in the patient record indicating why the radiographs were ordered and/or what was found (diagnosed) by the doctor upon reviewing the prescribed films.

There is no liability for payment by a patient or insurance company for simply taking radiographs. There is liability for payment when the dentist puts on the hat of radiologist and determines that there is, or is not, suspected pathology and subsequently enters those findings in the patient record as a separate dated and signed report, or, even better, as part of the treatment record for that day's visit. Read carefully: If there is no documentation of radiographic findings, there is no liability for payment. In this situation, if payments have already been made, the office may indeed be required to refund those monies.

The need for radiographs is not being determined by the benefit plan; the criteria are based solely on the clinical needs of the patient as documented in the patient's record.

The ADA Council on Scientific Affairs in JADA, Vol.132, February 2001, p.234 specified:

“Routine use of radiography as a part of periodic examinations (evaluations) of all patients is an inappropriate practice. Because each patient is different from the next, radiographic examination should be individualized . The nature and extent of the diagnosis required for patient care constitute the only rational basis for determining the need, type and frequency of radiographic examination.”

The panoramic film is sometimes considered to be a superior diagnostic tool by both general practitioners as well as specialists. Healthcare professionals consider the jaws, associated components, their function, and related pathology to be entirely within the realm of the dental profession. Given the magnitude of this responsibility, it is clear that the first step on the way to a thorough diagnosis might well begin with a “global” radiographic interpretation of all related anatomical landmarks. Not that the panoramic can, or should, replace indicated bitewings or the selected use of a periapical, but the scope of interpretation through many individual films simply cannot match the global aspect of the panoramic film, nor the simplicity of orienting the patient to understand where we are viewing and what we are identifying.

So how does all this relate to your office bank deposit? Should it be legislated that all radiographs be paid by all plans whenever they are deemed necessary and appropriate by the treating dentist? What entity will determine appropriate care? What science will be used? Should frequency and benefit limits ever be placed, considered or enforced?

The patient must acknowledge and be accountable to you for their total cost of care prior to considering the dollar value of any insurance benefits. Yes, the total fee. If not – evidence based parameters of care will in fact become the benefit plans parameter of payment. But then again, some might think that this could be a good thing.

Tom Limoli, Jr. is the author of “Dental Insurance & Reimbursement Coding and Claim Submission Manual”. If you're not sure what code to use to bill the patient's benefit plan then this book is for you. To order click here.

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