ODA Working Group helps resolve dental insurance issues, including scaling and root planing reimbursements, denials of core build up claims
Every month, a dedicated group of Ohio Dental Association member dentists volunteer their time to serve during conference call meetings of the ODA Dental Insurance Working Group (DIWG). These dentists determine the ODA’s role in addressing dental insurance related questions, concerns and complaints involving third-party payers that are submitted by ODA member dentists.
Case studies from the working group’s efforts from this year alone demonstrate the value of membership to the individual dentists who contacted the ODA for assistance while also generating information that the rest of the membership can utilize in their own practices. They also represent cases where the individual dentists were ineffective in addressing their concerns to dental insurance companies and needed the strength of the larger organization to obtain some form of relief from their concerns.
Scaling and root planing
Numerous member dentists have contacted the ODA over the past year regarding their concerns with the way a major dental insurer has been handling periodontal scaling and root planing claims, particularly claims involving full mouth scaling and root planing done on the same date of service. The DIWG’s ensuing response to the members’ concerns has resulted in an ongoing and productive dialogue between the ODA and the insurer to address both entities’ concerns about the issue. While this collaboration may yield even greater results with respect to disputed claims review determinations, it has already led to a clearer understanding of what dentists need to do in order to be reimbursed for providing a full mouth scaling and root planing service during one appointment.
Specifically, dentists should expect their full mouth scaling and root planing claims to be disallowed if they fail to devote an appropriate amount of time to doing the service. Providing supporting documentation that the procedure was done during a single visit because 1) the patient was sedated or 2) medically compromised or 3) the dental office location required the patient to travel some distance to get there or 4) the patient requested the service for their own purposes will improve the likelihood of getting the claim approved.
Additional documentary guidance can be found in the “CDT 2018 Coding Companion (Help Guide for the Dental Team),” which states “a full periodontal charting should be present, which includes not only pocket depths, but also recession, amount of attached gingiva, furcation involvement, mobility, bleeding on probing and any other periodontal condition found. The charting should be recent, usually less than six months old. Radiographic images should typically be less than one year old. Periapical images are preferred over bitewing or panoramic images.”
To decrease the chances of claim denials and/or unfavorable audit results, dentists should also understand the type of documentation that third-party payers will likely want to see. This documentation can likely include: full-mouth periodontal charting (including four to six probing depths per tooth, indication of furcation involvement, mobility or bleeding upon probing), full-mouth X-rays, periodontal diagnosis and what it was based on (e.g., radiographic evidence of bone loss, pocket depths of 4mm or more, bleeding on probing to indicate periodontal disease, possibly a radiographic image showing calculus and recording of teeth per quadrant), case type, treatment plan, treatment record (e.g., recording the planing was also performed and not just scaling, anesthetic carpules used) and an appointment book showing an appropriate time frame for providing the scaling and root planing service.
Core buildups
Another member dentist contacted the ODA regarding his concerns about an insurance denial of a core build-up claim because the carrier’s explanation of benefits (EOB) stated “benefits are not provided for this service as it is considered to be a part of, and inclusive to, the primary service performed.”
The ODA contacted the carrier and pointed out that the “CDT 2018: Dental Procedure Codes” (CDT) continues to recognize the core buildup procedure as a separate and distinct procedure from the crown procedure and, as such, to state or infer otherwise on an EOB is inaccurate and misleading to the patient/subscriber and the dentist. Accordingly, the ODA requested the carrier reconsider its claim denial and/or the EOB justification it is using to deny the claims in order to more accurately reflect the basis for the denial.
“The benefits contained in the patient’s benefit plan will ultimately determine if the core buildup service is covered or not,” said Dr. David Kimberly, Chairman of the ODA Council on Dental Care Programs and Dental Practice. “If the carrier does not reverse or revise its determination, then, at a minimum, the dentist has the ODA’s letter to show his patient that he properly submitted the claim on the patient’s behalf and any core buildup coverage problems are not the result of his actions.”
The CDT 2018 refers to the D2950 (core buildup, including any pins when required) code as the “building up of coronal structure when there is insufficient retention for a separate extracoronal restorative procedure. A core buildup is not a filler to eliminate any undercut, box form, or concave irregularity in a preparation.”
To put the patient and dentist in the best position to receive benefits, it may likely be necessary to submit a narrative with the core buildup claim. “In Coding with Confidence: The ‘Go To’ Dental Coding Guide: (2017 CDT Edition),” Dr. Charles Blair points out that in addition to providing the appropriate radiograph, information to detail the necessity of the core buildup in the narrative may include: a listing of any missing cusps; estimated percentage of healthy tooth structure left after fracture, caries and/or any previous restoration is removed; documentation of “any existing circumferential caries at gingival margin and extensive caries detectable by explorer under existing crown;” statement if the “tooth has existing or planed root canal therapy;” the tooth’s endodontic and periodontal prognosis; and, if applicable, a statement that the tooth has less than 2mm of remaining vertical height “the number of degrees of circumference of the tooth where this exists, e.g., ‘only 1mm of vertical tooth height remains around 270 degrees of tooth circumference.’” All of this information should also be documented in the patient’s chart.
Resources
“Too often member dentists don’t realize the resources that are available through organized dentistry to assist them in addressing dental insurance issues,” Kimberly said. “There are many ways the ODA and ADA can help members ranging from advocacy to providing general dental insurance information and education to individualized attention, and they’re all just a website search, phone call or email away.”
Resources available to member dentists though the ODA include the “ODA Today’s” monthly column addressing dental insurance issues and the dental insurance section of the ODA website, phone and/or email support via the ODA staff by calling (800) 282-1526, Carnation Dental/Direct Reimbursement website and flyers at www.CarnationDental.com, Contract Analysis Service and the Dental Insurance Working Group by contacting the ODA. Current DIWG members include: Drs. Erin Astley (Wellington); Jackie Cerar (Mentor); Gerry Espeleta (Englewood); Mary Ann Hanlon (Cincinnati); David Kimberly (Akron); Purnima Kumar (Columbus); Michael Lee (Cincinnati); Gregory Michaels (Lancaster); Jason Streem (Cleveland); and David Vorherr (Cincinnati).
Resources available to member dentists though the ADA include dental insurance webinars, numerous publications and guides, phone and/or email support via the ADA staff, the dental benefits section of the ADA Center for Professional Success website (success.ada.org/en/dental-benefits), Credentialing Service (ada.org/en/member-center/member-benefits/practice-resources/ada-credentialing-service) and Contract Analysis Service (www.ada.org/en/member-center/member-benefits/legal-resources/contract-analysis-service).
Interested in learning more about dental coding?
Be sure to check out Dr. Charles Blair’s course “Stay Out of Jail: Avoid Coding Errors and Excel in Insurance Administration” from 2-5 p.m. Sept. 14 at the ODA Annual Session. Register and learn more at www.oda.org/events with course code F54.
