Getting a Handle on Dental Coding: Ignorance is NOT Bliss

Cathy Stewart, RDH, BS, manager for professional education at Philips Oral Healthcare, explains why it’s essential dental hygienists become familiar with dental insurance codes.

There is a special “language” that is required to submit dental insurance claims: The American Dental Association’s (ADA) Current Dental Terminology (CDT)¹ system was designed to provide standardized codes and descriptors to report dental procedures. It is the only Health Insurance Portability and Accountability Act (HIPAA)-recognized code set for dentistry.

Did you know there are 13 CDT codes for oral evaluations? Did you know that in the 2021 edition there is a new code for “Caries Preventive Medicament Application-Per Tooth”? Are you familiar with the codes related to dental hygiene services?

I will admit that I practiced for more than 5 years before I even paid attention to CDT codes or had any idea why I should! Then I started my first non-clinical dental hygiene career role as a customer service team member for a major dental insurance carrier.

It quickly became apparent to me that it is essential for dental hygienists to know more about our business within a business. We don’t need to look at insurance carriers as the bad guys! Although we do not want to ever allow insurance benefits to dictate treatment decisions, it is possible to partner with our patients and their insurance carriers to maximize legitimate reimbursement.

Confusion about dental insurance is common. What plan, who is covered, what are the benefits, when does the plan year start? It is confusing to our patients, to us, and our patients expect us to be the experts, and sometimes even the customer service reps for the insurance company can be confused!

The business part of your team needs to be fluent in dental insurance “speak.” But, it is very helpful, and I strongly suggest that the clinical team obtain a basic knowledge of the most frequently used codes.

The ADA Council on Dental Benefits Programs has a Code Maintenance Committee that is responsible for reviewing and updating the CDT code set annually. In the past, the CDT book was updated every 5 years. It is now updated annually. It is important to replace your code book each year. Per Charles Blair, DDS, author of “Coding with Confidence: The Go To Dental Coding Guide,”² only about 30% of dentists get the updated code set annually. This puts you at risk to submit incorrect claims. In the 2021 edition of the CDT, there are 28 new procedure codes, 7 code revisions, 22 editorial revisions and 4 code deletions. If you are submitting a code you “have always used” you may get a claim denied. If your financial team has insurance cheat sheets, those can get outdated quickly! Would you want your accountant to use last year’s tax tables?

Dental benefit plans are a contract between the insurance company and the patient’s employer. In addition to annual maximums and deductibles, there are frequently limitations and exclusions that apply to dental benefit plans.

Are you familiar with these standard policy limitations and exclusions?

Pre-existing clause: If a tooth was missing prior to the patient’s effective date on their plan, benefits to replace that tooth may be excluded.
Cosmetic
Waiting period: Time before benefits are allowed.
Alternate benefit: LEAT-Least Expensive Alternate Treatment.
Seat vs prep date: This is especially important at year-end. If a plan only covers a crown/bridge on seat date, and the patient does not return for the seat until January, it may be subject to a new calendar year deductible. If the patient is no longer employed, there may be zero benefit.
Non-covered service: This is contract language. It has nothing to do with medical necessity. The plan does not cover certain procedures regardless of patient need.

If you have a claim denied, it helps to first review the plan limitation and exclusions. If the denial does not fall in those categories, you may want to file an appeal.

Appeal/Narrative Tips:

Be concise/detailed
Include attachments that are clearly labeled with the patient name, claim/member #, and date
Copies of radiographs need to be labeled left and right
Copy State Board of Insurance, if you feel it is necessary
Copy the patient

Have you ever been asked by a patient to change a code or date of service on a claim?

Make sure to code your claims based on what treatment you provided and only on the date that the service was done! You do NOT want to commit insurance fraud, even unintentionally! Do not be tempted to change codes to increase your patient’s benefits, even if they ask you to do it! You have an ethical reputation and a license to protect.

Audits do occur and in the case of an audit; ignorance is definitely not bliss!

Dental fraud is any crime where an individual receives insurance money for filing a false claim.

These are some examples of fraud as outlined by the United Concordia Insurance Companies Inc:

Billing for services not provided
“Upcoding” (example: submitting a sealant as a one-surface composite)
Submitting a claim under one person’s name when services were provided to another person
Altering claim forms and dental records
Billing for non-covered services as if they were covered services
Changing the date on a claim so it falls within a patient’s benefit period
Routinely waiving co-payments or deductibles
Performing services that are not suitable or “necessary”

It is worth your time to learn more about dental coding. Knowledge is power, but only if you apply that knowledge. There is comfort in knowing you are providing excellent patient care while legally and ethically maximizing their insurance benefits.