Many practices still depend on the front office to work up the codes and treatment plan from a form or document forwarded from the back office. The clinical notes may not always include the detailed information needed to match the code nomenclature. Often questions are skipped in a rush to print up the treatment plan as the patient is usually on the way up to the desk.
Dr. James Anderson.
The front office team member may choose a code that is not a correct match for the treatment to be provided. This mistake could result in an insurance claim overpayment/underpayment or a denial for lack of supporting documentation. To be compliant and avoid audits, it is imperative to use the correct codes representing the treatment provided.
The treating dentist listed as the provider of services on the claim form is responsible for all information submitted on the claim, including the choice of procedure codes, diagnosis codes, and narratives. Even if the dentist is an employee and not the owner, he or she is still responsible.
The importance of dental codes
The ADA is the overseeing agency that consistently looks at trends and needs related to dental procedures and translates those to the Code on Dental Procedures and Nomenclature (CDT Code). The ADA states that the purpose of the code set is to "achieve uniformity, consistency and specificity in accurately documenting dental treatment."
As a part of the ADA, the Council on Dental Benefit Programs is responsible for maintaining the codes through an established group called the Code Maintenance Committee (CMC). This committee includes various representatives from the dental specialty groups and third-party payers, and each group's representative serves as a voting party in the decision-making process. Every spring, the CMC reviews all submitted proposals and ultimately votes to add, delete, or amend codes for use the following calendar year.
One use of the CDT Code is to provide for the efficient processing of dental claims. Another is to populate electronic health records. Furthermore, HIPAA establishes the need to report codes using the current properly mandated 2021 CDT Code set.
The insurance market is now dominated by preferred provider networks (PPOs), which won't change anytime soon. To get maximum legitimate reimbursement, you need to have a current codebook, know how to read it, and understand the relationship with coding sets, matching codes, and codes that complement each other. Sometimes combining the wrong codes will result in denials of treatment because the codes cancel each other out.
Each specific dental plan defines what is not reimbursed based on its policy contract provisions. It is getting harder to achieve reimbursement for claims other than preventative and basic because of the insurance plan's clauses that allow it to reduce payment and deny services where there are benefits.
Using 2018 or even last year's codes leaves you short of many new codes, revised codes, and deleted codes. Insurance plans do not correct the codes you submit, and you will get a denial or a request for more information. While you get into sending appeals and trying to figure out what you did wrong, your insurance accounts receivables are growing -- and so is the pile of bills that need to be paid.
Choose the right code for 2021
Choosing the correct code is about selecting the most current code that fits the procedure, not a code that paid in the past or one that you have always used in the same circumstance. That code you are so fond of may not exist any longer or may have been revised and no longer corresponds to the service you provide.
The rule of coding is to code what you do; however, many practices struggle with choosing the correct code that matches what they have done. Part of yearly training would be to examine the new codes and any revised codes to understand how to submit these codes for payment.
Just because the code fits the treatment doesn't mean the payer will pay the claim. Reimbursement depends on whether the plan offers the service as a covered benefit and what criteria must be met before the claim is adjudicated or released for payment.
Some practices update their dental software yearly, and with that, the codes are also updated. Some familiar codes may be deleted or revised, or there may be a new code altogether. The complexities of coding call for having the best tools available.
If you haven't acquired CDT books from the ADA, Dr. Charles Blair's Coding with Confidence, or another trusted source, you are now really in a pickle. This year brought some new dental insurance codes, revised some existing codes, and deleted a few from use. We can look forward to changes that will help us more clearly represent the services we provide for our patients and enhance the metrics for tracking those services.
Notable new codes for 2021
There are 28 new codes for 2021. These are some of the most notable additions that took effect in January:
- D0604: Antigen testing for a public health-related pathogen, including coronavirus
- D0605: Antibody testing for a public health-related pathogen, including coronavirus
- D1355: Caries preventive medicament -- per tooth (this can include silver diamine fluoride application)
- D5995 and D5996: Periodontal medicament carrier with peripheral seal -- laboratory processed, maxillary and mandibular, respectively
Please note the codes for the periodontal medicament carrier are respective to the arches and were created to replace the deleted CDT Code D5994, which did not specify the arch. In light of the current pandemic, COVID-19 antigen and antibody testing will be allowed by dental professionals in some states depending on the states' dental practice acts.
Don't leave thousands of dollars on the table because you and your team don't know how to code your claims. Don't leave yourself open to an audit or worse by choosing codes that don't represent the treatment that you provided. Documentation that is complete and accurate affects the entire practice's reputation and the bottom line.
Dr. James Anderson is a practicing dentist in Syracuse, UT, and is the CEO and founder of eAssist Dental Solutions. He can be reached via email.
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