Stop Telling Patients About Their Dental Insurance - It's The Patient's Plan!

1. 800-344-
800-344-2633
www.LIMOLI.com

2. 1924 - 2006

4. Basic Housekeeping
Indoor Plumbing
Outdoor Plumbing
Emergency Evacuation
g y
Phones and Pagers
Handouts
Questions
Q ti

5. Who is here today?
Dentists
Hygienists
H gienists
Business A
B i Agents
t
Chair Side Assistants
Ch i Sid A i t t

6. Why are you
here today?

7. Why Am I Here?
Minimize The Impact Of The Patients
Dental Benefit Plan On Your
Practice
Simplify And Streamline The
Reimbursement Process
Educate Customers And Clients To
Enhance Patient Care

8. Don’t Be Afraid Of The Patients
Don’
Dental Insurance

9. Dental Benefit Plan
Any plan is simply a device
which those individuals in
the work force are using to
help offset the cost of dental
care

10. Dental / health plans are
not intended to pay for
the wants and needs of
the patients
p

11. You Get What You Pay For
Premiums Paid In For Dental
Benefit Plan
Determine Benefits Paid Out
For Treatment

12. Where Did Patients Plan Come
From And Where Is It GGoing?
?

15. Henry J Kaiser
J.

16. And It All Started In 1938 For Only
A Nickel A Day Per Employee or
Family Member

20. Health insurance has
thrived because the
cost is a deductible
ti d d tibl
item for the plan
purchaser as well as
g
labor and management

21. Comprehensive health
p
plans are one way that
y
employees in the work
force have received
Tax Free Benefits

22. Congress has looked at the
business tax deduction and
they are losing not only the
revenue from it,
but they also feel there is no
fiscal responsibility on the
fi l ibili h
part of the individual

24. Federal Trade
Commission
Promotes open
competition in the
United States economy

25. Be Advised
The Federal Trade Commission
is strictly enforcing laws against
anti-competitive behavior
anti-competiti e beha ior
through the
g
Department of Justice
Use care and judgment when
adjusting YOUR fee schedule

27. Are Health Plans a
Right or a Privilege?

28. It’s Election Season
So
S Be C f
Careful

29. What is motivating the
g
“Patients’ Bill of
Patients’
Rights?”
Rights?”
Is It Need or Greed?

31. National Association of
Dental Plans
“The size of the dental
benefits market can be
reliably estimated at 192
million lives - or 69% of the
US population”
population”

32. What Kind Of Coverage
Do They Have?

33. 192 Million Lives
19% 13%
HMO
PPO
Traditional
37% Referral
31%

34. Where’s The Money?
Where’

35. Self Funded Plans
The sponsor does not purchase
conventional insurance. Claims
are paid through the services of a
third party administrator with the
direct funds of the employer.

36. Fiduciary
Of,
Of pertaining to, or involving
to
one who holds something ing
trust for another
The keeper and director of
funds

37. Fiduciary Responsibility
The plan administrator (insurance
company) acting in behalf of the plan
purchaser (
h (employer) t pay any and
l ) to d
all claims that are due and payable
based upon the terms of the specific
contract.

38. The Administrator is Paid
4% to 6% of the face value of the
check generated to the dentist.
If the dentist is not paid, the plan
administrator is not paid
p
Procedure codes changed to
payment codes

39. Like Your Bank Insurance
Bank,
Companies and Third Party
Administrators Make Money
By Moving Information For
Their Clients
Very Few Claims Are Paid
With Their Money

40. How Is The Doctor Paid?
At What Rate?

41. Usual Fee
The fee that an individual dentist
most frequently charges for a
specific dental procedure
independent of any contractual
agreement.

42. Customary Fee
The fee level determined by the
administrator of a dental benefit plan
from actual submitted f
f t l b itt d fees for a
f
specific dental procedure to establish
the maximum benefits payable under
a given p
g plan for that specific
p
procedure.

43. Reasonable Fee
The fee charged by a dentist for a
specific dental procedure that has
been modified b th nature and
b difi d by the t d
severity of the condition being treated
and by any medical or dental
complication or unusual
p
circumstances.

44. It’s The Individual Plan,
It’
Not The Insurance Company

45. Appropriate Coding Is
The K T P fit bl
Th Key To Profitable
Reimbursement
Tom M. Limoli, Jr

46. Current Dental
Terminology
The Code on
Dental
Procedures and
Nomenclature
Nomenclat re

47. CDT 2011-2012
2011-

48. And We Have More
Code Changes on the
way for 2013

49. Is CDT
The Roadmap to
Evidence B
E id Based
d
Parameters
of Care?

50. Appropriate Coding
Diagnostic
Preventive
Restorative
Endodontic
Periodontal
Implants
Adjunctive

51. Diagnostic
What is the code number for
fabricating a p
g periodontal chart?
What about the periodontal
evaluation code?

52. Pre-
Pre-Diagnostic Services
New for 2013
D0190 screening of a patient
– A screening, including state and federally
mandated screenings, to determine an
individual’
individual’s need to be seen by a dentist for
diagnosis

53. Pre-
Pre-Diagnostic Services
New for 2013
D0191 assessment of a patient
– A limited clinical inspection that is performed
to identify possible signs of oral or systemic
disease, malformation, or injury, and the
, , j y,
potential need for referral for diagnosis and
treatment

54. Evaluations
The codes in this section have been revised
to recognize the cognitive skills necessary
for patient evaluation The collection and
evaluation.
recording of some data and components
of the dental examination may be
delegated; however, the evaluation,
diagnosis and treatment planning are the
responsibility of the dentist.

55. Evaluations
As with all ADA procedure codes there is no
codes,
distinction made between the evaluations
provided by general practitioners and
specialists. Report additional diagnostic
and/or definitive procedures separately
separately.

56. To Reach A Documented
Conclusion or Diagnosis
g

57. Evaluations
D0120 periodic
D0140 limited
D0145 under 3 years of age
D0150 comprehensive
D0160 d t il d and extensive,
detailed d t i
– by report
D0170 re-evaluation – limited
re-
D0180 comprehensive periodontal

58. Periodic Oral Evaluation
An evaluation performed on a patient of
record to determine any changes in
the patient’s d t l and medical
th patient’ dental d
ti tt’ di l
health status since a previous
comprehensive or periodic evaluation.

59. with CDT-7 was added
CDT-
This includes an oral cancer
evaluation and periodontal
screening where indicated and
indicated,
may require interpretation of
information acquired th
i f ti i d throughh
additional diagnostic p
g procedures.
Report additional diagnostic
procedures separately.

60. Limited Oral Evaluation
An evaluation limited to a specific oral
health problem. This may require
interpretation of information acquired
i t t ti fi f ti i d
through additional diagnostic
procedures.

61. Problem Focused
Typically,
Typically patients receiving this type of
evaluation have been referred for a
specific problem and/or present with
ifi bl d/ t ith
dental emergencies, trauma, acute
infections, etc..

62. Comprehensive Oral
Evaluation
Used by a general dentist and/or a
specialist when evaluating a patient
i li t h l ti ti t
comprehensively. It is a thorough
evaluation and recording of the
e t ao a and t ao a a d and soft
extraoral a d intraoral hard a d so t
tissues.

63. Comprehensive
This includes an evaluation for oral
cancer where indicated, the
evaluation and recording of th
l ti d di f the
patient’s dental and medical history
and a general health assessment.

64. Comprehensive
It may include the evaluation and
recording of dental caries, missing or
unerupted teeth restorations existing
teeth, restorations,
prostheses, occlusal relationships,
periodontal conditions (including
periodontal charting), hard and soft
tissue anomalies, etc
anomalies etc.

65. Detailed and Extensive
A detailed and extensive problem-
problem-
focused evaluation entails extensive
diagnostic and cognitive modalities
di ti d iti d liti
based on the findings of a
comprehensive oral evaluation.

66. Detailed and Extensive
Integration of more extensive
diagnostic modalities to develop a
treatment plan for a specific problem
t t t l f ifi bl
is required. The condition requiring
this type of evaluation should be
described and documented.

67. Problem focused by report
focused,
Examples of conditions requiring this type of
evaluation may include dentofacial
anomalies, complicated perio-prosthetic
anomalies perio-
conditions, complex temporomandibular
dysfunction,
dysfunction facial pain of unknown origin
origin,
severe systemic diseases requiring multi-
multi-
disciplinary consultation etc
consultation, etc..

68. D0170
Re-
Re-evaluation - limited,
problem focused
Established ti t
E t bli h d patient;
not post-operative visit.
p
post- p
Assessing the status of a previously
existing condition.
condition

69. What are the global aspect of
the procedure and condition?

70. Comprehensive
Periodontal Evaluation
New or established patients
showing signs or symptoms of
periodontal disease and for the
patients with risk factors such
as smoking or di b t
ki diabetes.

71. D0180
It includes evaluation of periodontal
conditions, probing and charting,
evaluation and recording of the
patient’s dental and medical
patient’
history and general health
assessment.
t

72. D0180
It may include the evaluation and
recording of dental caries,
missing or unerupted teeth,
restorations,
restorations occlusal
relationships and oral cancer
evaluation.
l ti

73. How Often Can I
Charge For A New
Comprehensive
Evaluation?
How about the new or
established patient?
t bli h d ti t?

74. With CDT-2005
CDT-
The text
“significant change in health
status or other unusual
circumstances, by report”
“three or more years”
is added to the descriptor

75. What About Office
Visits and That New
Code For Case
Presentations
Can we charge for those?

76. Professional Visits
D9430 office visit for observation
(during regular scheduled hours)
– no other services performed
D9440 office visit – after regularly
g y
scheduled hours
D9450 case presentation, detailed
presentation
and extensive treatment planning

77. Radiographs
and
Diagnostic
Imaging

79. New For 2013
D0391 interpretation of diagnostic image
by a practitioner not associated with the
capture of the image including report
image,
– W now have image capture both with and
We h i t b th ith d
without interpretation
– Complete series no longer includes bitewings
– “radiographic image” replaces “film”
image” film”

80. Radiographic
Frequency?
Complete S i
C l t Series
Two Bitewings
Four Bitewings
Panoramic Film

81. Don’t Schedule Based On The
Don’
Calendar or Benefit Plan

82. JADA, Vol. 132,
February 2001
“Diagnostic radiographs should be
g g p
used only after clinical
examination,
examination consideration of the
patient’s history and
patient’
consideration of both the dental
and the general health needs of
the patient.”
patient.”

83. ADA Council on Scientific Affairs
“Routine use of “The nature and extent
radiography as part of of the diagnosis
periodic evaluation of required for patient
all patients is an care constitute the
inappropriate only rational basis for
practice”
practice”
ti determining th need,
d t i i the d
type and
frequency ”
frequency…

84. “Radiographs Are Not To
g p
Be Taken Until The Doctors
Hands Or Eyes H
H d O E Have B
Been
In The Patient’s Mouth”
Patient’ Mouth”
Health and Human Services
Public Health Service
Food and Drug Administration
HHS Publication 88-8273
88-
Revised 2004

87. Diagnostic Imaging
D0350 oral/facial photographic
images
– This includes photographic images,
including those obtained by
g y
intraoral and extraoral cameras,
excluding radiographic images
images.
These images should be a part of
the patient’s clinical record.
record

90. New for 2013
Coding Cone Beam
Less than one whole jaw
One full dental arch – mandible
One full dental arch – maxilla
– With or without cranium
TMJ series
With and Without Interpretation

92. Tests and Laboratory
Examinations
D0425 caries susceptibility tests
– not to be used for carious d ti staining
tt b df i dentin t i i
D0460 pulp vitality tests
– Includes multiple teeth and
contralateral comparison(s), as
p ( )
indicated.
D0470 diagnostic casts

93. Miscellaneous Services
D9950 occlusion analysis – mounted
case
– Includes, but is not limited to,
facebow, interocclusal records
tracings, and diagnostic wax-up; for
wax-
diagnostic casts see D0470
casts,

96. What is a (brush)
biopsy?

97. Other Surgical Procedures
D7286 biopsy of oral tissue –
soft (all other)
–F surgical removal of
For i l l f
specimen only. This code is not
p y
used at the same time as codes
for apicoectomy / periradicular
curettage.

98. with CDT-2005
CDT 2005
D7288 was the new code
number and the descriptor
was simply changed from
py g
Cytology to Transepithelial
Sample Collection

99. Tests and Examinations
D0431 adjunctive per-diagnostic test that
per-
aids in the detection of mucosal
abnormalities including p
g premalignant and
g
malignant, not to include cytology or
biopsy procedures
This is the code number for most of the
other oral cancer
screening techniques

100. Preventive
How do you get paid for a two
visit prophy?
p p y

101. Prophylaxis - Adult
A dental prophylaxis performed on
transitional or permanent dentition
which includes scaling and
polishing procedures to remove
coronal plaque, calculus and
stains.
t i

102. with CDT-2005
CDT-
Descriptor changed to removal
of plaque, calculus and stain
p q ,
from the tooth structure…
As well as local irritational
factors…
factors

103. Some patients may require more
than one appointment or one
extended appointment to
complete a prophylaxis
prophylaxis.
Document need for additional
time or appointments.
ti i t t

104. Let’s Do Some Claims
Let’

105. Doctor
D t Clinical
Cli i l
Diagnosis Findings
Code Narrative /
Attachment

107. •No attachment loss
No
•No bone loss
•Abundance of plaque,
calculus and stain
“Last f i
“L t professionall
D1110 Prophylaxis cleaning was 24
months ago”
ago

108. Don’t bill the benefit
Don’
plan until the prophy is
complete
“S
Some patients may require more than
ti t i th
one appointment or one extended
appointment to complete a prophylaxis.
i t tt l t h l i
Document need for additional time or
appointments.”
appointments.”
i t t
Charge the patient a reasonable fee

109. Fluoride Treatment
Prescription strength fluoride
p
product designed solely for
g y
use in the dental office,
delivered to the dentition under
the direct supervision of a
p
dental professional

110. Topical Application Treatment
D1206 fluoride varnish
D1208 fluoride
Deleted in 2013 were
D1203 and D1204

111. D1120
Prophylaxis - Child
Refers to a (routine) dental
( )
prophylaxis performed on
primary or t
i transitional
iti l
dentition only.
y

112. If The Dental
Assistant Does The
Coronal Polishing,
g,
What Code Number
Do We Use?
Is it a prophy?

113. O
Other Preventive S
Services
D1330 oral hygiene
instructions
–This may include instructions for
home care. Examples include
tooth brushing technique,
flossing, use of special oral
hygiene aids.
h i id

114. Preventive or
Restorative?
How about air abrasion?

115. Other Preventive Services
D1351 sealant - per tooth
– Mechanically and/or chemically
prepared enamel surface sealed to
p
prevent decay.
y

116. with CDT-4 was added
CDT-
D2391 resin-based composite
resin-
-one surface posterior
p
Used to restore a carious lesion in
the d ti
th dentin or a ddeeply eroded
l d d
area into the dentin. Not a
preventive procedure.

117. Sealant – per tooth
“Mechanically and/or chemically
prepared enamel surface sealed
to prevent decay”
decay”
These are not preventive resin
p
restorations

118. D1352
preventive resin restoration in a
moderate to high caries risk
patient – permanent tooth
Conservative restoration of an active
cavitated l i i a pit or fi
i d lesion in i fissure that d
h does
not extend into dentin; included placement
of sealant in any radiating non-carious
f l i di i non- i
fissure or pit

119. Restorative
What code numbers identify the
new generation of hybrid
restorative materials?

120. with CDT-4 was added
CDT-
“Local anesthesia is considered to
be part of restorative procedure”

121. since CDT-2005
CDT-
Descriptor reads
“Local anesthesia is usually
Local
considered to be part of the
restorative procedure”

122. What about Anesthesia?
D9210 local not in conjunction with
j
operative or surgical procedure
D9211 regional bl k
i l block
D9212 trigeminal division block
D9215 local in conjunction with
j
operative or surgical procedure

123. What About Nitrous?
D9230 inhalation of
nitrous oxide / anxiolysis
anxiolysis,
analgesia

124. Amalgam Restorations
Tooth preparation all adhesives
preparation,
(including amalgam bonding agents),
liners and b
li d bases are i l d d as part
included t
of the restoration. If pins are used,
they should be reported separately
(
(see 02951) )

125. Primary or Permanent
Amalgam
D2140 one surface
D2150 two surfaces
D2160 three surfaces
D2161 four or more surfaces
f f

127. Identification of Surfaces
Mesial toward the middle
Distal away from the middle
Lingual
Li l facing the tongue
f i th t
Buccal facing the cheek
Occlusal chewing surface of posterior
Incisal cutting surface of anterior

128. Resin Based Restorations
Resin f
R i refers t a broad category
to b d t
of materials including but not
g
limited to composites. May
include bonded composite
composite,
light-
light-cured composite, etc..

129. Resin Restorations
Tooth preparation light-curing, acid-etching
preparation, light-curing acid-etching,
and adhesives (including resin bonding
agents) are included as part of the
restoration. Glass ionomers, when used as
restorations,
restorations should be reported with these
codes.
If pins are used report separately
used,

130. New Generation
Restorative Materials
Sinfony®
Targis®
Targis/Vectris/Ribbond®
T i /V t i /Ribb d
Bellglass HP®
Cristobal+®
RESIN RESTORATIONS

131. New Generation
Restorative Materials
Procera AllCeram®
In-Ceram ®
In-
Cera Glass ®
Cera-
C -Gl
IPS Empress ®
IPS Eris E2 ®
PORCELAIN/CERAMIC

132. Porcelain / ceramic refers t
P l i i f to
those non-metal, non-resin
non- non-
inorganic refractory compounds
processed at high temperatures
(600°C / 1112°F and above)
(600° 1112°
and pressed, polished or milled
– including porcelains, glasses
and glass – ceramics
ceramics.

133. New in 2013
e 0 3
Porcelain / Ceramic
Refers to pressed, fired, polished or milled
materials containing “predominantly”
predominantly”
inorganic refractory compounds including
g y p g
porcelains, glasses, ceramics and glass
ceramics

134. Resin refers to any resin –
based composite, including
p , g
fiber or ceramic reinforced
polymer compound

135. 1100 degree rule

136. Inlay / Onlay
Metallic
D2510 inlay - one surface
D2520 inlay - two surfaces
D2530 inlay three or more surfaces
i l - th f
D2542 onlay - two surfaces
D2543 onlay - three surfaces
D2544 onlay - four or more surfaces

137. Inlay / Onlay
Porcelain - Ceramic
D2610 inlay - one surface
D2620 inlay - two surfaces
D2630 inlay three or more surfaces
i l - th f
D2642 onlay - two surfaces
D2643 onlay - three surfaces
D2644 onlay - four or more surfaces

138. Inlay / Onlay
Resin-
Resin-Based Composite
D2650 inlay - one surface
D2651 inlay - two surfaces
D2652 inlay three or more surfaces
i l - th f
D2662 onlay - two surfaces
D2663 onlay - three surfaces
D2664 onlay - four or more surfaces

140. Resin based composite
inlays/onlays must utilize
y y
indirect technique.
Is it laboratory processed?
What about
CEREC and LAVA?

141. Noble Metal Content
high noble - Gold Palladium, and/or
Gold, Palladium
Platinum 60% (with at least 40% Au)
noble - Gold, Palladium, and/or
Platinum 25%
predominantly base - Gold,
Palladium, and/or Platinum < 25%
Palladium

142. Sorry,
Sorry
Titanium i not a
Tit i is t
noble metal
Atomic number 22
Atomic
At i weight 47 9
i ht 47.9

143. with CDT-4 was added
CDT-
separate classification
t l ifi ti
Titanium and titanium
alloys ( 85%)
ll (>85%)

144. www.IDENTALLOY.org
www IDENTALLOY org

145. What was a sedative filling?
D2940 sedative filling
– Temporary restoration intended to
relieve pain.
– Not to be used as a base or liner
under a restoration

146. New in 2013
D2940 protective restoration
Direct placement of a temporary restorative
material to protect tooth and/or tissue
form. This procedure may be used to
relieve pain, promote healing, or prevent
further deterioration. Not to be used for
endodontic access closure, or as a base
or liner under a restoration.

148. Other Restorative Services
D2950 core buildup including any
buildup,
pins
– Refers to building up of anatomical
crown when restorative crown will
be placed, whether or not pins are
used
D2951 pin retention - per tooth, in
addition t restoration
dditi to t ti

149. with CDT-4 was added
CDT-
A material i placed i th t th
t i l is l d in the tooth
preparation for a crown when there
is insufficient t th strength and
i i ffi i t tooth t th d
retention for the crown procedure.
This h ld t be
Thi should not b reported when
t d h
the procedure only involves a filler
to eliminate any undercut, box
form, or concave irregularity in the
preparation.

150. Your Clinical
Documentation Must
Confirm
50% or > loss of coronal tooth
structure and not a full 2-3 mm
2-
collar of sound tooth structure at
the gingival margin

152. Post and Core
D2952 post and core in addition to
crown, indirectly fabricated
– post and core are custom fabricated
as a single unit.
D2954 prefabricated post and core in
addition to crown
– Core is built around a prefabricated
post. This procedure includes the
core material.

154. Additional Posts
D2953 each additional indirectly
fabricated post – same tooth
p
– to be used with 02952
D2957 each additional prefabricated
post – same tooth
– to be used with 02954

155. D2799 provisional crown
Crown utilized as an interim
restoration of at least 6 months
duration during restorative
treatment to allow adequate
time for healing or completion of
ti f h li l ti f
other procedures.
p

156. D2799 provisional crown
This includes but is not limited to
includes, to,
changing vertical dimension,
completing periodontal th
l ti i d t l therapy or
cracked tooth syndrome.
This is not to be used for a temporary
crown for a routine prosthetic
restoration.

157. Now in 2013
D2799 provisional crown
– Future treatment or completion of diagnosis
necessary prior to final impression Not to be
impression.
used as a temporary crown for a routine
prosthetic restoration

158. Other Restorative Services
D2970 temporary crown (fractured tooth)
– Usually preformed artificial crown, which
is fitted over a damaged tooth as an
immediate protective device. This is not
to be used as temporization during
p g
crown fabrication.
– Deleted w/ CDT-2005 and later
CDT-
resurrected w/ CDT-2007
CDT-

159. New in 2013
D2929 prefabricated porcelain / ceramic
crown – primary tooth
D2990 resin infiltration of incipient
smooth surface lesion
th f l i
– Placement of an infiltrating resin restoration
for t
f strengthening, stabilizing and/or li iti
th i t bili i d/ limiting
the progression of the lesion

160. Redefined with 2013
D2955 post removal (not in conjunction
with endodontic therapy)
D2980 crown repair necessitated by
restorative material failure
D2981 inlay repair
D2982 onlay repair
D2983 veneer repair

161. Other Restorative Services
D2980 crown repair by report
repair,
– Includes removal of crown, if necessary.
Describe procedure
procedure.
D2999 unspecified restorative procedure,
by report
– Use for procedure which is not adequately
described by a code Describe procedure
code. procedure.

162. Plan Provisions
90th Percentile
Alternate Benefit
Coordination of Benefit
Maintenance of Benefit
Non duplication of Benefit
Date of Incurred Liability
Birthday Rule
Predetermination

163. Benefit Plan
Provisions Must Be
Confirmed With Each
New Series Of Visits

164. Your office must
follow the benefit
plan provisions
provisions.
Providership is not a
consideration or
excuse.
excuse

165. Even if you are not a
designated plan
provider,
provider you must
still follow the rules

167. Secure Specifics In
Writing From The
g
Plan Or Make Other
Financial
Arrangements.
Arrangements
Get The Benefit Booklet
From The Patient – The
www or Fax Back

169. Always C fi Eli ibilit
Al Confirm Eligibility
With Each Appointment
If you file the claim,
it’s your responsibilit
it’ o r responsibility

170. Eligibility
Benefit Card
Call the day of the patient visit
Reference #
Name of contact
Don’t forget the employer
Don’
Web based plan access

171. How and how much
the plan pays

172. What is the 90th
percentile and how is
p
it computed?
p

173. Surcharge
The stated dollar amount paid to the
dentist by the beneficiary, in addition
to th
t other reimbursements received b
i b t i d by
the third-party payer(s)
third-

174. Table of Allowances
A list of covered services with an
assigned dollar amount that
represents the total obligation of the
t th t t l bli ti f th
plan with respect to payment for such
services, but does not necessarily
represent the dentist’s full fee for that
p dentist’
service.

175. Maximum Allowance
The maximum dollar amount a dental
program will pay toward the cost of a
dental
d t l service as specified i th
i ifi d in the
program’s contract provision.
program’

176. Prevailing Fee
Term used by some dental benefit
organizations to refer to the fee most
commonly charged f a d t l
l h d for dental
service in a given area.
Frequently the 51st percentile

177. But what fee goes
on the claim form?
Your full “USUAL” fee
USUAL”
We will talk about
discounts later

178. Alternate Benefit
A provision in a dental plan
contract that allows the third-party
third-
payer to determine the benefits
based on an alternate procedure
that is generally less expensive
then th
th the one provided or
id d
p p
proposed

179. with alternate benefit
The plan is not dictating
treatment, they are only
, y y
determining coverage based
upon that plans specific
contract language
g g

180. Why the plan does
not pay?
Exclusions, limitations
and carve outs of
coverage

181. Coordination of Benefits
A method of integrating benefits
payable under more than one plan
The benefit plans work together
Benefits from all sources do not
exceed 100% of the total charge

182. Maintenance of Benefits
A method of restricting benefits
payable under more than one plan
Secondary plan pays no more than if
it were primary
If primary plan pays, secondary plan
does not

183. Nonduplication of Benefits
A method of restricting benefits
payable under more than one plan
If primary plan pays, secondary plan
does not
If primary plan does not pay,
secondary plan may/may not

184. The Problem
Elimination and/or reduction of
secondary coverage's
y g
although premiums paid by
both primary and secondary
beneficiaries

185. The Solution
Don’t accept authorization for
Don’
payment on secondary coverage
Have the plan reimburse the patient
Financial arrangements based on
primary coverage

186. Rules of Primacy
The plan covering the patient as
anything other than a dependent is
primary
i
The plan without a COB p
p provision is
primary
Lowest dollar threshold is primary

187. What is the date of
incurred liability

188. Dental benefits are payable
after the effective date of
ft th ff ti d t f
coverage. However
coverage However,
dentures, bridgework and
g
root canals are liabilities:
Dentures-
Dentures-impression is taken
Bridgework-
Bridgework-teeth are prepared
Root Canal-tooth opened by
Canal-
dentist

189. The payer has the
p y
right to ask the
g
p
provider
Prep Date
Impression Date
Seat D t
S t Date

190. With most all benefit
p
plans, services are
not payable or
p y
reimbursable until
they are completed
y p
Make this work in your
favor

191. Assignment of Benefits
A procedure whereby a beneficiary
authorizes the administrator of the
program to forward payment for
covered procedures directly to the
treating dentist.

192. Assignment of
Benefits is not an
Authorization for
Payment
P t

193. Primacy of
coverage with
dependent children
Birthday Rule
Effective D t R l
Eff ti Date Rule
Gender Rule

194. Birthday Rule
The primary payer is determined by
the birth date of the insured
parents
First in the calendar year is primary

195. Effective Date Rule
The primary payer is determined by
the parent whose policy has the
oldest effective date

196. Gender Rule
The primary payer of benefits is
father’ p
the father’s plan

197. Extended Families

198. Preauthorization
Precertification
Predetermination
Prior Authorization

199. When should you?
When shouldn’t you?
shouldn’
When do you have to??
Why do you have to?
Why should you have to?
Why shouldn’t you have to?
y shouldn’ y

200. simply defined as:
an indication of the dollar
amount to be paid for covered
p
services contingent upon
continuing eligibility

201. First Instance
Important for the patient to know
approximately how much their dental
benefit plan may pay.
Determines full cost of treatment before
treatment is actually started.

202. Second Instance
Since we have no record of having
received a predetermination…
Treatment plan exceeded $250
Benefits are payable for only
diagnostic,
diagnostic preventive and palliative
services

203. Third Instance
Uncooperative patient with no printed
benefit information
“I have insurance and my husband has
insurance. Everything is paid at 100%
in full”

204. Never a guarantee
of reimbursement
You can’t take it to the
can’
bank

205. Discounts
Total Fee Charged (Question 53) must be
the fee you intend to collect.
It is illegal to discount based on the
p
patients co-payment.
co-p y
Discount must be disclosed when the
claim is filed
filed.

206. Overpayments
Eligibility Confirmed Immediately
Prior to treatment?
Coordination of benefits?
Payer Fraud?
Payer Error?
Utilization Review?

207. We are responsible
p
for submitting timely
and accurate claims
Therefore, we must keep
the system simple

209. Endodontic
We started a root canal and
the patient did not return.
How do we get paid?

210. Pulp Cap
D3110 direct
– Procedure in which the exposed
pulp is covered with a dressing or
cement that protects the p p and
p pulp
promotes healing and repair.
– Excludes final restoration

211. Pulp Cap
D3120 indirect
– Procedure in which the nearly
exposed pulp is covered with a
p
protective dressing to p
g protect the
pulp from additional injury and to
promote healing and repair via
formation of secondary dentin.
– E l d fi l restoration
Excludes final t ti

212. Pulp Capping procedure
codes are not identifying
cement bases or cavity liners.
They are simply part of the
final restoration

214. D3220 therapeutic pulpotomy
surgical removal of a portion of the pulp
with the aim of maintaining the vitality of
the remaining portion by means of an
adequate dressing
– performed on primary or permanent
teeth
– not first stage of root canal therapy
t fi t t f t l th
– excluding final restoration

216. D3221 pulpectomy
pulpal debridement primary and
debridement,
permanent teeth
– for the relief of acute pain prior to
conventional root canal therapy py
– not to be used by provider
completing endodontic treatment

217. with CDT-4 was added
CDT-
“This procedure is not to be used
when endodontic treatment is
completed on the same day”

218. Endodontic Therapy
Pulpectomy is part of root canal
therapy. Includes all appointments
necessary to complete treatment;
l
also includes intra-operative
intra-
radiographs. Does not include
diagnostic evaluation and
necessary radiographs/diagnostic
images.
images

219. Endodontic Therapy
D3310 anterior
– Excluding final restoration
D3320 bicuspid
– Excluding final restoration
D3330 molar
– Excluding final restoration

220. Endodontic Retreatment
This procedure may include the
removal of a post, pin(s), old root
canal filli material, and th
l filling t i l d the
procedures necessary to prepare the
canals and place the canal filling.
Includes complete root canal therapy.
p therapy.
py

221. Endodontic Retreatment
D3346 anterior
D3347 bicuspid
D3348 molar
– The post removal is now unbundled from the
global procedure
– Submit with treatment notes by report
y p

222. Answer the following?
Who did the original root canal?
When was it done?
How and what f il d?
H d h t failed?
– occlusion
– decay
– trauma
How was it retreated?

223. Endodontic Therapy
D3332 incomplete endodontic
therapy; inoperable, unrestorable or
fractured tooth
f t d t th
Considerable time is necessary to
determine diagnosis and/or provide
initial treatment before the fracture
makes the tooth unretainable

224. New in CDT 2011-2012
2011-
D3354 pulpal regeneration –
(completion of regenerative
( p g
treatment in an immature
permanent tooth with a necrotic
pulp); does not include final
restoration

225. D3354 – pulpal regeneration
Includes removal of intra-canal medication
intra-
and procedures necessary to regenerate
continued root development and
necessary radiographs.
This procedure includes placement of a
seal at the coronal portion of the root canal
system.
system
Conventional root canal treatment is not
performed.
f d

226. Apexification /
Recalcification
D3351 initial visit
D3352 interim medication replacement
D3353 final visit
– includes completed root canal therapy

228. Other Endodontic
Procedures
D3999 unspecified endodontic
procedure, by report
procedure
– Used for procedure which is not
p
adequately described by a code.
Describe procedure.

229. Periodontal
How do you sequence the coding
of non-surgical periodontal
non-
treatment for maximum
reimbursement?

230. ICD-
ICD-10 vs.
SNODENT
Systematized
Nomenclature of
Dentistry

231. Annals of Periodontology,
Volume 4, 1999
I.
I Gingival Diseases
II. Chronic Periodontitis
III. Aggressive Periodontitis
IV.
IV Periodontitis as a Manifestation
of Systemic Diseases

232. Annals of Periodontology,
Volume 4, 1999
V.
V Necrotizing P i d t l Di
N ti i Periodontal Diseases
VI. Abscesses of the Periodontium
VII. Periodontitis associated with
Endodontic Lesions
VIII. Development of Acquired
Deformities and Conditions

233. Periodontal Case
Types
What is being treated?
In what anatomic area is
hat
it being treated?
g

234. Gingival Disease
Inflammation of the gingiva
characterized clinically by changes in
color, gingival f
l i i l form, position, surface
iti f
appearance, and presence of
bleeding and or exudate

235. Early Periodontitis
Progression of the gingival
inflammation into deeper periodontal
structures and alveolar b
t t d l l bone crest, t
with slight bone loss. There is usually
a slight loss of connective tissue
attachment and alveolar bone

236. Moderate Periodontitis
A more advanced stage of the above
condition, with increased destruction of the
periodontal structure and noticeable loss
of bone support, possibly accompanied by
an increase in tooth mobility There may
mobility.
be furcation involvement in multi-rooted
multi-
teeth

237. Advanced Periodontitis
Further progression of periodontitis with
major loss of alveolar bone support
usually accompanied b i
ll i d by increased
d
tooth mobility.
Furcation involvement in multi-rooted
multi-
teeth is likely

238. Refractory Periodontitis
Includes those patients with multiple
disease sites which continue to
demonstrate attachment loss after
appropriate therapy. These sites
presumably continue to be infected by
periodontal pathogens no matter how
thorough or frequent the treatment
provided

239. Anatomic Area
Being Treated?
Per Tooth
Per Site
Per Sit Per Quadrant
P Site -P Q d t
Per Quadrant
Per Arch
Per M th
P Mouth

240. Areas of the Oral Cavity
00 entire oral cavity
ti l it
01 maxillary arch
y
02 mandibular arch
10 upper right quadrant
20 upper left quadrant
30 lower left quadrant
40 lower right quadrant

241. Gingivectomy / Gingivoplasty
It is performed to eliminate
suprabony pockets or to restore
normal architecture when gingival
enlargements or asymmetrical or
unaesthetic topography is evident
with normal b
ith l bony configurations
fi ti

242. Surgical Services
D4210 gingivectomy or gingivoplasty
– Four or more contiguous teeth or
bounded teeth spaces per quad
D4211 gingivectomy or gingivoplasty
– One to three teeth per quad
teeth,

243. New for 2013
D4212 gingivectomy or gingivoplasty to
allow access for restorative procedure,
– per tooth

244. Surgical Services
D4230 anatomical crown exposure
– four or more contiguous teeth
– per quadrant
d t
D4231 anatomical crown exposure
– one to three teeth
– per quadrant

245. Surgical Services
D4249 clinical crown lengthening
– hard tissue
With adjacent teeth, the crown
teeth
lengthening of a single tooth will
involve a minimum of th
i l i i f three t th
teeth.

246. Clinical Crown Lengthening
This procedure is employed to allow
restorative procedure or crown with
little
littl or no tooth structure exposed to
t th t t dt
the oral cavity. Crown lengthening
requires reflection of a flap and is
p
performed in a healthy py periodontal
environment...

247. Surgical Services
D4260 osseous surgery
– including flap entry and closure
– four or more bounded teeth spaces per
quadrant
Modifies the bony support of the teeth by
reshaping the alveolar process to achieve
physiologic form. Procedure must include
the removal of supporting bone.

248. Scaling and Root Planing
Involves instrumentation of the crown
and root surfaces of the teeth to
remove plaque and calculus f
l d l l from
these surfaces. It is indicated for
patients with periodontal disease and
is therapeutic, not p p y
p , prophylactic, in
,
nature.

249. Scaling and Root Planing
Root planing is the definitive procedure
designed for the removal of
cementum and dentin that is rough
and/or permeated by calculus or
contaminated with toxins or
microorganisms. It may be used as a
definitive treatment or as part of a
pre-
pre-surgical procedures.

250. Adjunctive Periodontal
Services
D4341 scaling and root planing
– Four or more teeth per quadrant
Some soft tissue removal occurs.

251. What about the
patient who need
only limited scaling
and root planing?
What code number do
we use?

252. Adjunctive Periodontal
Services
D4342 scaling and root planing
– one to three teeth per quadrant
Some soft tissue removal occurs.

253. Non-
Non-Surgical
Periodontal Service
D4355 full mouth debridement
to
t enable comprehensive
bl h i
evaluation and diagnosis
g

256. D4355
The gross removal of plaque
and calculus that interfere with
the ability of the dentist to
perform a comprehensive oral
evaluation.
l i
This preliminary procedure
does not preclude the need for
additional procedures
procedures.

257. D4355
When an evaluation
evaluation,
diagnosis and
radiographs are not
possible.
Not
N t a routine procedure
ti d

258. “Gross scaling
without root planing is
no more
than prophylaxis”
prophylaxis”
JADA, March 1987

259. Adjunctive Periodontal
j
Services
D4381 localized delivery of
y
antimicrobial agents via a
controlled release vehicle into
diseased crevicular tissue,
– per t th
tooth
– by report
y p

260. D4381 redefined
38 ede ed
FDA approved subgingival delivery
devices containing antimicrobial
medications are inserted into the
periodontal pockets to suppress the
pathogenic microbiota. These devices
microbiota
slowly release the pharmacological
agents so they can remain at the
intended site of action in a therapeutic
concentration for a length of time.
t ti f l th f ti

261. Forget about the trade
name of the product
Tell the payer about the
drug,
drug its concentration and
dosage

262. Other Periodontal
Services
D4910 periodontal maintenance
procedures (following active therapy)
This procedure is for p
p patients who have
previously been treated for
periodontal disease
disease.

263. D4910
This procedure is instituted following
periodontal therapy and continues at
varying i t
i intervals, d t
l determined b th
i d by the
clinical evaluation of the dentist, for
the life of the dentition or any implant
replacement.
p

264. D4910 Includes
Removal of the bacterial plaque and
calculus from supragingival and
subgingival regions
b i i l i
Site specific scaling and root p
p g planing
g
where indicated (D4341 or D4342)
and
polishing of the teeth (D1110).

265. Wh t b t th
What about the
evaluation?
Is it charged out
separately?
Can the hygienist do the
evaluation?

266. “Periodic
maintenance
i t
treatment following
t t t f ll i
periodontal therapy is
not synonymous with
a prophylaxis”
prophylaxis”

267. Never alternate
N lt t
D4910 with D1110

268. Sequential Order of
Treatment
Diagnose First
Treat based on diagnosis
Evaluate treatment
Continue treatment
Continue evaluation

270. Questions?

271. Complete Dentures
D5110 maxillary
D5120 mandibular
D5130 immediate maxillary
D5140 immediate mandibular
D5810 interim maxillary
D5811 interim mandibular
D5860 overdenture – complete, by report
p , y p

272. Partial Dentures
D5211 maxillary resin base
y
D5212 mandibular resin base
D5213 maxillary cast metal w/resin b
ill l / i base
D5214 mandibular cast metal w/ base
D5225 maxillary w/ flexible base
D5226
5 6 mandibular w/ flexible base
a d bu a / e b e
D5861 overdenture – partial, by report

273. Removable Prosthetics
Adjustments to Dentures
Repairs to Dentures
Repairs to Partial Dentures
Denture Rebase Procedures
Denture Reline Procedures

274. New in CDT 2011-2012
2011-
D5993 maintenance and
cleaning of a maxillofacial
g
prosthesis (extra or intraoral)
other than required
adjustments, by report
j , y p

275. Implants
The surgeon placed the implant
and we did the prosthesis.
Who codes for what?

276. D6010
Surgical placement of implant
body: endosteal implant
Includes second stage surgery and
placement of healing cap

278. deleted code D6020
Abutment placement or
substitution: endosteal implant
An abutment is placed to permit
fabrication of a dental prosthesis.
p
This procedure may include the
removal of a temporary healing cap
or replacement with an abutment of
alternate design
design.

280. Implant Abutments
D6056 prefabricated –
– includes modification and
placement
– Modification of a prefabricated
abutment may be necessary

281. Implant Abutments
D6057 custom fabricated
– includes placement
– created by a laboratory process,
specific for an individual application

282. New for 2013
D6051 interim abutment
– Includes placement and removal
– A healing cap is not an interim abutment
D6104 bbone graft at time of implant
ft t ti fi l t
placement

283. Implant Supported
Prosthetics
D6053 D6062 D6067 D6073
D6054 D6063 D6068 D6074
D6058 D6064 D6069 D6194
D6059 D6094 D6070 D6075
D6060 D6065 D6071 D6076
D6061 D6066 D6072 D6077

284. New in CDT 2011-2012
2011-
D6254 interim pontic
D6795 interim retainer crown
Used
U d as an i t i restoration f a d ti of
interim t ti for duration f
less than six months when a final impression
is not made to allow adequate time for healing
or completion of definitive treatment planning.
These are not temporary pontics and retainer
p yp
crowns for routine prosthetic fixed partial
denture restoration.

285. Peace at Last

287. Snoring Appliances
D5999 unspecified maxillofacial
prosthesis, by report
physician referral
copy of sleep study showing
confirmed di
fi d diagnosis
i

288. Is it a medical
liability or a
dental
d t l
p
prosthesis?
Let the plans decide so the
patient can pay the bill

289. Extractions
Includes Local Anesthesia
Anesthesia,
Suturing, If Needed, and
g, ,
Routine Postoperative Care

290. Extractions
D7111 coronal remnants –
deciduous tooth
– soft tissue retained coronal remnants
D7140 erupted tooth or exposed root
p p
(elevation and/or forceps removal)
– Includes routine removal of tooth
structure, minor smoothing of socket
bone and closure, as necessary
closure

291. Surgical Extractions
Redefined in CDT 2011-2012
2011-
D7210 surgical removal of erupted
tooth requiring removal of bone
and/or sectioning of tooth, and
d/ ti i f t th d
including elevation of mucoperiosteal
flap if indicated
– Includes cutting of g g
g gingiva and bone,,
removal to tooth structure, minor
smoothing of socket bone and closure
g

292. New in CDT 2011-2012
2011-
D7251 coronectomy – intentional
partial tooth removal
Intentional partial tooth removal is
performed when a neurovascular
complication is likely if the entire
impacted tooth is removed
removed.

293. Adjunctive
Why aren’t we being paid
Wh aren’ e
for palliative procedures?

294. D9110
Palliative (emergency ) treatment of
dental pain - minor procedure
This is typically reported on a “per
visit” basis for emergency treatment
g y
of dental pain

295. Adjunctive
When is a narrative report or
supplemental attachment
necessary?

296. Are We Now Ready
To Get The Correct
Information To
The Patients
Insurance Company?
p y

297. Health Insurance Association
of America (AHIP)
Nine out of 10 claims are
processed within 21 days of receipt
p y p
Almost 16% of claims are received
more than 60 days after services
have been provided to the patient
Almost half of all claim
delays/denials (48%) are due to the
submission of duplicate claims

298. Send all of your claims and
attachments electronically

299. Electronic Claims and
Attachments
Practice Management System
Electronic Claims Vendor
www. Based All Payer - Player
Freedom of Choice
Beware the Unethical Billing
Service

301. What about
signature on fil ?
i t file?

302. Coding and
g
Reimbursement
Management is Simple
Follow Tom’s
Tom’
Seven Keys to
Reimbursement Success

303. Rule 1
Diagnose and document
prior to initiating any
treatment

304. Rule 2
Establish a written
treatment plan for the
patient as well as
y
yourself

305. Rule 3
Secure financial
arrangements prior to
treatment

306. Rule 4
Patient must acknowledge
and agree to pay the
total fee prior to
insurance consideration

307. Rule 5
Bill and code for exactly
what services are
rendered

308. Rule 6
What the insurance does
not pay - the patient
must pay

309. Rule 7
If the patient does not pay
- hunt them down like
you would a rabid dog

311. Thank You For
Joining Us
Please Drive
Safely
and
Courteously
C t l