Common Dental Insurance
Coding Errors

Joseph D. Jordan, JD & Dr. Charles Blair

Insurance coding is a subject that faces you everyday in your professional career. Every practicing dentist has problems with insurance coding. It is an area that, if mastered, will ensure that you are maximizing your returns in your practice. Approach it with indifference and you will leave money on the table everyday, which can also lead to multiple problems if audited.
Although coding errors are as broad as the codes are long, we have compiled a list of the top coding errors made on a regular basis in a new practice. Don’t be guilty of making unnecessary mistakes and losing the legitimate profits you have worked for.
Now, on to the list!

 

  1. Using the recall oral evaluation (D0120) instead of D0150 for the child comprehensive (initial) exam to hold down the fee. You should establish two fees (adult and child) for the same code D0150, with the following fee philosophy. Use D0150A and D0150B to consistently distinguish between the child and adult fee levels. Thus, the overall reimbursement will be higher and the correct code reported.
  2. Consider using fewer problem-focused evaluations (D0140) (which are generally limited to “two exams per twelve months”) and use more palliative evaluations (D9110) as appropriate.
    Using two bitewings (D0272) for adults instead of four bitewings (D0274) as standard clinical protocols. Using two bitewings (D0272) applies to children, and four bitewings (D0274) generally applies to adults.
  3. Ensure that pan/full series are initiated and regularly updated in accordance with the clinical protocol as set by the dentist (typically every 3 to 5 years).
    In the GP office, use D0150 for comprehensive evaluation patients who have signs and symptoms of perio at the initial exam, not D0180. Use D0150 for all new patients, unless the age is less than three years of age (use D0145).
  4. Miscoding the type of metal crown (hi-noble, noble, base, etc.) performed is a common error. Report the correct metal-related code.
  5. Bridge pontic metal-type does not match bridge retainer metal-type, a common error.
    Using the anterior root canal code (D3310) for a single rooted bicuspid. The office should report D3320 for all bicuspid teeth, regardless of number of roots.
  6. Using chairside reline codes for an in-office processed (oven, pressure bath, etc.) reline. You should use lab reline codes if reline is processed either in the office or an outside lab, because a lab reline reimbursement is higher than a chairside reline.
  7. Charging bitewing x-ray at emergency (problem-focused) visit (D0140), which may exhaust the annual BWX availability for a subsequent recall visit. Periapical x-rays at emergency visits generally don’t count against annual BWX availability. Consider periapical films, which give more diagnostic information, in accordance with the dentist’s protocol.
  8. Misusing full mouth debridement to enable comprehensive evaluation and diagnosis (D4355), as a “first visit prophy.” This code is only to be used where the initial oral evaluation cannot be performed by dentist due to calculus and debris buildup. The comprehensive oral evaluation (D0150) follows on a subsequent date.
  9. Not using the immediate denture code (D5130/D5140) when extracting the remaining natural teeth and immediately placing a denture. The immediate denture service is followed by a reline, rebase, or a new complete denture. Some payors require a six month healing interval after the extraction/insertion date. On the other hand, an interim complete denture (D5810/D5811) is placed in an already edentulous mouth for a limited period, to be replaced by a more definitive restoration, such as an overdenture.
  10. Not using the palliative code (D9110) at routine emergency visits for minor procedures to alleviate spontaneous pain/discomfort, a common occurrence.
  11. Not using abutment-supported or implant crown coding (D6xxx) as required by the current CDT 2007/2008 codes while coding these implant-type crowns as routine single crowns (D29xx) for natural teeth. Natural tooth coding could be considered fraudulent, if intentional.
    Using coronal remnants (D7111) for all routine deciduous (baby) tooth extractions. Should use routine extraction code, (D7140), if primary (deciduous) root structures remain and it is not a coronal remnant.
  12. Reporting a routine extraction as a surgical extraction (D7210) if a suture is placed. The D7210 surgical extraction code for the erupted tooth requires “lay a flap plus removal of bone and/or section tooth” to qualify.
  13. Charging for a base in addition to an amalgam/composite restoration on the same service date. All bases and liners are now included in the restoration under CDT 2007/2008.
  14. Miscoding pulpal therapy (D3230/D3240) on necrotic primary teeth as pulpotomies (D3220). Pulpotomies are performed on vital teeth, while pulpal therapy (D3230/D3240) is performed on necrotic primary teeth, with resorbable medicament placed down the canals. The UCR may be higher for D3230/D3240, so report it appropriately.
  15. Miscoding “soft-tissue crown lengthening” as “hard-tissue crown lengthening” (D4249). Crown lengthening requires reflection of a flap and removal of hard tissue (bone) to change the crown to root ratio. Many payors require six weeks healing period to then be followed by the crown preparation and impression.
    Coding single crown buildup types such as D2950, D2952, D2953, D2954, and D2957 instead of fixed bridge retainer buildups (D6970, D6972 and D6973). Use bridge retainer buildup codes appropriately for bridgework.
  16. Using consultation (D9310) for either treatment plan presentations or for patients who are seeking second opinions. Consultation (D9310) is a referral from a dentist/physician for rendering a second opinion by the consulting doctor who may or may not be performing the treatment. Instead, use case presentation (D9450) after the initial evaluation service date. Report D0140/D0150/D0180 for new patient oral evaluations when a patient is requesting second opinion related to a single service or a comprehensive treatment plan.
  17. Using D9450 for treatment plan presentations on a date subsequent to the comprehensive oral evaluations (D0150/D0180). This is generally not reimbursed.
  18. A “preventative” resin-based composite procedure is miscoded as D2391. Composite restorations must restore carious lesions extending into the dentin. On the other hand, preparations and caries into the enamel are considered only sealants (D1351).
  19. Not using D2335 for anterior restoration involving incisal angle, which is the corner of the tooth. The incisal edge (biting edge) is reported as a one, two or three surface restoration, depending on the doctor’s preparation of the tooth.
  20. Miscoding the various buildup codes, often coding the prefabricated post and core (D2954) as a cast post and core (D2952) or vice versa.
  21. For some PPO providers, reporting exclusively the one surface anterior composite code (D2391) for all legitimate one, two and three surface composite restorations. Just because a certain PPO provider requires coding with its third-party contract that way, doesn’t mean the rest of the dental world follows it. Always report the actual procedures performed. Let the carrier reimburse according to any policy limitations and exclusions. Note: Code and report exactly “what you do,” strictly in accordance with CDT 2007/2008.
  22. DO NOT REPORT a separate pan (D0330) and bitewings (D0272 or D0274) as equivalent to a full series (D0210). Report the pan/bitewing procedures separately (as actually performed) and let the carrier “remap” for the full series alternative payment, according to any policy limitations and exclusions. Always report “what you do.”
  23. The D0170 re-evaluation code should not be used as a “follow-up” for routine treatment, i.e. root planning and scaling. Your fee for any initial treatment should cover any post-op evaluation associated with that code. D0170 is for “assessing the status of previously existing condition” such as traumatic injury or lesion requiring a follow-up evaluation visit (D0170).
  24. Pulp vitality test (D0460) is a “stand-alone” code. However, payors often count it as an “evaluation” for purposes of the “two evaluation per year” limitation. Also, the UCR fee is often below the problem-focused evaluation code (D0140). Most policies limit the benefits to either the problem-focused exam (D0140) or the pulp vitality test (D0460) on the same service date.
  25. Miscoding of chairside reline procedures as tissue conditionings (D5850/D5851). The purpose of tissue conditioning treatment (for a limited period) is to heal unhealthy ridges prior to a definitive, removable prosthesis. It is not long-term. The purpose of tissue conditioning is to prepare tissues for an impression.
  26. Not reporting the abutment codes separate from the abutment-supported crown. The implant abutment codes (D6056/D6057) now include the labor component for placement.
  27. Misusing D7250, surgical removal of residual tooth roots (cutting procedure). Use of this code for “difficult” erupted tooth extractions may invalidate reimbursement for a bridge, partial, or implant-type crown. Plan limitations may require a tooth in occlusion to qualify for replacement. “Residual tooth roots” reports the surgical removal of existing roots of previously extracted teeth.
    Misusing occlusal orthotic device (D7880) as an occlusal guard. D7880 is for TMJ (pain/clicking jaw) while occlusal guard (D9940) alleviates bruxing/clenching.
  28. Misusing D8210/D8220 removable appliance therapy code for minor tooth movement with Hawley/springs, such as to correct a crossbite. (D8210/D8220) includes removable harmful habit appliances for thumb sucking and tongue thrusting. Often the code interceptive orthodontic treatment of the transitional dentition (D8060), is appropriate for minor tooth movement.
  29. Using office visit for observation (D9430) as a “billing” code. Often not payable. Consider D9110 or D0140, if applicable.
  30. Using D3960 - obsolete code for internal bleaching. Report internal bleaching-per tooth (D9974) for bleaching root canal teeth.

By getting an early start on the correct coding, you can ensure that you are in compliance with the law as well as maximizing your legitimate insurance re-imbursements. Although insurance coding can be a daunting task, don’t be discouraged. Use your resources and watch your mastery of the CDT codes grow! ■

Joseph D. Jordan, JD, offers services to new dentists in the area of transitions, associateships, business planning and collections. He can be reached at 704.827.5676 or by email at jjordan@legaldent.com.

Dr. Charles Blair offers strategic planning, coaching to new dentists regarding training on proper fee alignment, correct insurance coding, and analyzing practices, existing or recently purchased. His newly updated insurance coding handbook, “Coding with Confidence: The Go-To Guide for CDT 2009/2010” is available on his website at www.drcharlesblair.com. For more details, email him at charles@drcharlesblair.com or call 866.858.7596.

 

 

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