Insurance payment denial for multiple surface restorations on the same tooth frustrates dentists and their business teams. Dentists must document the procedures performed as the clinical evidence dictates, yet insurance payers have limitations that police reimbursement. Heated discussions involving dentists over coding multiple surface restorations become complicated when the costs of these services color decisions.
We turn to the CDT 2023 Current Dental Terminology to clarify the surface descriptions. On page 17 of CDT 2023, the ADA explains the codes D2000-D2999.
There are five surface classifications: mesial, distal, incisal or occlusal, lingual, or facial (labial). If the tooth needs a one-surface restoration, one of these classifications must be indicated to determine the location for charting/treatment purposes and proper claim submittal. The same classification applies if the tooth needs multiple surfaces to restore it.
Tooth surfaces are reported on the HIPAA standard electronic dental transaction and the ADA claim form using the letters of abbreviation:
- Buccal - B
- Facial (or labial) - F
- Incisal - I (anterior)
- Distal - D
- Lingual - L
- Mesial - M
- Occlusal - O (posterior)
If there are two or more surfaces on a single tooth, the provider will list the surfaces based on whether they are interrupted or there is no interruption. For instance, if the restoration is an MO, it encompasses the mesial and occlusal surfaces as one uninterrupted restoration.
However, if healthy tooth structures separate the mesial and occlusal surfaces, it is an M and an O restoration. It must be listed as two separate restorations on the chart and the insurance claim form. If the provider lists the restoration as an MO (uninterrupted) on the claim form, it may be denied or downgraded to one surface and paid as such.
The issue compounds when two separate two-surface restorations are on the same tooth. Many dental plans advise reporting an MO and a DO as a MOD. Doing so is incorrect.
Dentists must accurately document two separate two-surface restorations as an MO and a DO, as the clinical scenario dictates. Failure to do so may lead to discrepancies between patient charting records and the plan's claim records, which can cause problems during audits or service reviews.
A strategy to optimize reimbursement for multisurface restorations
Before initiating treatment, verify patients' insurance coverage and clarify any restrictions, limitations, or exclusions specific to multisurface restorations. This step can be done two ways: through a sometimes lengthy phone call or by submitting a predetermination of benefits.
If the patient can be scheduled three weeks out, you’ll have time to receive the response. A definite response enables accurate treatment planning and appropriate patient communication regarding out-of-pocket costs, which in turn improves your collections, boosts patient confidence in treatment planning, and patient satisfaction due to a reduction in surprise balance bills.
The remapping (downcoding to the least expensive alternative treatment of multisurface restorations for in- and out-of-network claims) is subject to the policy’s processing policies. Many plans typically do not disclose their bundling or downcoding policies, even during the contract negotiation process.
Dentists and patients have no way of knowing what the reimbursement will be until the explanation of benefits is received. The results differ depending on which provider (in or out of network) they see. In network, the plan may bundle two separate restorations into one and prohibit the doctor from billing the patient for the balance. The plan may pay for the alternate three-surface restoration out of network but allow the dentist to bill the patient for the balance of the underpaid procedures.
Tip: Some dental plans have clauses restricting coverage on the same surface twice on the same service date. In this situation, dental plans may apply an alternate benefit clause, leading to lower reimbursement as a single three-surface restoration.
Below is a sample reimbursement explanation from a multiple surface submittal and the subsequent dental plan adjudication:
"Tooth #22 (lower left cuspid) had two separate three-surface composites. Facial lingual mesial (FLM) and facial lingual distal (FLD). The dental plan rejected the FLM and only paid for the mesial surface. Essentially only paying for four surfaces."
Verify how the dental plan policy dictates coverage of multiple surface restorations before treatment. Treatment plan with the patient explaining the limitations of the insurance policy, the estimated benefits, and the out-of-pocket costs. Document the symptoms, diagnosis, and supporting evidence for proper records. Code what you do, not what the insurance pays.
Estela Vargas, CRDH, is the founder and CEO of Remote Sourcing, a dental insurance billing and revenue recovery service. She is a graduate of Miami Dade College's dental hygiene program. Vargas' extensive background in the clinical arena of dentistry is coupled with her experience as a practice administrator and business executive.
Belle DuCharme has been a dedicated writer, speaker, and consultant for the dental profession for decades. With a solid foundation in practice management and clinical experience, DuCharme has helped hundreds of dental clients achieve practice growth and stability. Her mission is to help other dental professionals create standards for financial and clinical success. You can reach her at email@example.com.
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