You're UNSTOPPABLE when you code correctly
- Updated:
- November 2022
- Topic:
- Coding
Ever felt like you were on top of a mountain, you feel the success because you pushed yourself to get there? But then you turn the corner and you see you have another peak to climb! Just like when you open the mail to find an EOB telling you a patient's claim was denied due to incorrect coding. We have all been there. With Practice Booster’s Online Code Advisor tool, any office can have it easy! Because it is confusing to know what code to use, here are four top questions and answers recently received in our call center support at Practice Booster. If you find this helpful and wish to obtain access to FAQs from prior weeks, submit your own coding question, and access the Online Code Advisor, CLICK HERE to discover the keys to maximizing your reimbursement and minimizing risk.
Helping your dental practice with coding accuracy, here are 4 Q & A recently inquired of:
1-Q: What code do I use when removing a fixed lingual retainer that's not a space maintainer? Should I use D8999?
Answer: If the same office fixed it initially, the payor may say it is a zero fee if a PPO insurance will be billed. If the procedure is periodontally related, then D4999. If ortho related, then D8999. If the office is replacing an ortho retainer in this situation, then D8703/D8704, depending on the arch.
2-Q: We have a patient who we had a root canal on, tooth #9, after a fall at college. This was submitted to her dental insurance and was covered. The tooth has now darkened and she is considering doing internal bleaching. I know her dental insurance does not cover this. Can this be submitted to her medical, as a result of the trauma, and do you see this typically being a covered service?
Answer: The D9974 is typically viewed as a patient expense and cosmetic procedure. I do not think the medical insurance would consider this at all even with the accident involved. As per the coding, there is no crossover medical code but if you wanted to file it you would use the 41899 Unlisted procedure, dentoalveolar structures and include a description of the service. Contact the patient's medical insurance to see if they offer accidental injury involving teeth coverage, and ask if the claim may be billed on an ADA claim form, if not allowed to utilize a medical claim form. The medical insurance may walk you through their claim submission process for dental billing. For further knowledge on medical/dental insurance billing, you will find a lot of helpful guidance in our Medical Dental Cross Coding With Confidence book.
3-Q: Code D4341 and D4342 periodontal scaling/root planing. Are these codes for more than 4mm or more than 5mm to get them paid by insurance?
Answer: Some companies are looking for 4mm and some for 5mm, so there is variation to be aware of. If they are looking for 5mm and they are 4mm then they don't meet their payment criteria. That doesn't mean the patient doesn't need SRP.
The documentation should include 4 items: 4-5mm pockets, BOP (Bleeding upon probing), radiographic bone loss, and bone loss on the charting-CAL (Clinical Attachment Level). Have a clear narrative, attach the periodontal charting and bitewing x-rays. If the patient is on any medications which may be contributing to the bone loss, include their medical health history in the attachments, as well as the narrative.
4-Q: We are creating an in-house membership plan for patients who do not hold dental insurance. I’m reaching out to see if there is anything legally keeping us from offering the plan to everyone. Are we allowed to only offer it to those patients who do not hold dental insurance?
Answer: Check with your state dental society and state board for any guidance plus your state insurance commissioner. This is for informational and training purposes only and is not considered legal advice. Always consult with your healthcare attorney for legal counsel. Generally, the traditional in-house insurance plan is set up for patients with no dental insurance. This typically covers checkup visits and a discounted fee schedule (10-15% off) for restorative, periodontics, endodontics, and major procedures.
In some cases, I've heard of dentists selling just a "discount plan" for a low fee (say $50). This way if a patient uses up their typical $1,500 dental insurance annual benefit, then they would receive a discount on the treatment above what insurance pays. This is complicated and if you choose this route, you need a specialized healthcare attorney to guide you.
Now that you have been edified by these top questions and answers, don’t you feel better knowing other dental professions experience the same questions. Check back again for our next blog post and CLICK HERE to discover the keys to maximizing your reimbursement and minimizing risk.
