Adacdt2013 slideshare


Published on

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

  • Be the first to comment

Adacdt2013 slideshare

  1. 1. 800-344-
  2. 2. 1924 - 2006
  3. 3. Basic HousekeepingIndoor PlumbingOutdoor PlumbingEmergency Evacuation g yPhones and PagersHandoutsQuestionsQ ti
  4. 4. Who is here today?DentistsHygienistsH gienistsBusiness AB i Agents tChair Side AssistantsCh i Sid A i t t
  5. 5. Why are youhere today?
  6. 6. 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
  7. 7. Don’t Be Afraid Of The PatientsDon’ Dental Insurance
  8. 8. Dental Benefit PlanAny plan is simply a device which those individuals in the work force are using tohelp offset the cost of dental care
  9. 9. Dental / health plans are not intended to pay for the wants and needs of the patients p
  10. 10. You Get What You Pay ForPremiums Paid In For Dental Benefit PlanDetermine Benefits Paid Out For Treatment
  11. 11. Where Did Patients Plan ComeFrom And Where Is It GGoing? ?
  12. 12. Henry J Kaiser J.
  13. 13. And It All Started In 1938 For Only A Nickel A Day Per Employee or Family Member
  14. 14. Health insurance has thrived because the cost is a deductible ti d d tibl item for the plan purchaser as well as glabor and management
  15. 15. Comprehensive healthpplans are one way that yemployees in the work force have received Tax Free Benefits
  16. 16. 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
  17. 17. Federal Trade Commission Promotes open competition in theUnited States economy
  18. 18. Be AdvisedThe 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
  19. 19. Are Health Plans aRight or a Privilege?
  20. 20. It’s Election Season So S Be C f Careful
  21. 21. What is motivating the g “Patients’ Bill of Patients’ Rights?” Rights?” Is It Need or Greed?
  22. 22. National Association of Dental Plans “The size of the dental benefits market can be reliably estimated at 192million lives - or 69% of the US population” population”
  23. 23. What Kind Of Coverage Do They Have?
  24. 24. 192 Million Lives 19% 13% HMO PPO Traditional 37% Referral31%
  25. 25. Where’s The Money?Where’
  26. 26. Self Funded PlansThe sponsor does not purchase conventional insurance. Claimsare paid through the services of a third party administrator with the direct funds of the employer.
  27. 27. FiduciaryOf,Of pertaining to, or involving to one who holds something ing trust for another The keeper and director of funds
  28. 28. Fiduciary Responsibility The plan administrator (insurancecompany) acting in behalf of the planpurchaser ( h (employer) t pay any and l ) to d all claims that are due and payablebased upon the terms of the specific contract.
  29. 29. The Administrator is Paid4% 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
  30. 30. Like Your Bank Insurance Bank,Companies and Third PartyAdministrators Make MoneyBy Moving Information For Their ClientsVery Few Claims Are Paid With Their Money
  31. 31. How Is The Doctor Paid? At What Rate?
  32. 32. Usual FeeThe fee that an individual dentist most frequently charges for a specific dental procedure independent of any contractual agreement.
  33. 33. Customary Fee The fee level determined by theadministrator of a dental benefit plan from actual submitted f f t l b itt d fees for a fspecific dental procedure to establishthe maximum benefits payable under a given p g plan for that specific p procedure.
  34. 34. 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 dseverity of the condition being treated and by any medical or dental complication or unusual p circumstances.
  35. 35. It’s The Individual Plan, It’Not The Insurance Company
  36. 36. Appropriate Coding IsThe K T P fit blTh Key To ProfitableReimbursementTom M. Limoli, Jr
  37. 37. Current Dental Terminology The Code on DentalProcedures and Nomenclature Nomenclat re
  38. 38. CDT 2011-2012 2011-
  39. 39. And We Have MoreCode Changes on the way for 2013
  40. 40. Is CDTThe Roadmap toEvidence BE id Based d Parameters of Care?
  41. 41. Appropriate CodingDiagnosticPreventiveRestorativeEndodonticPeriodontalImplantsAdjunctive
  42. 42. Diagnostic What is the code number forfabricating a p g periodontal chart? What about the periodontal evaluation code?
  43. 43. Pre- Pre-Diagnostic Services New for 2013D0190 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
  44. 44. Pre- Pre-Diagnostic Services New for 2013D0191 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
  45. 45. EvaluationsThe 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.
  46. 46. EvaluationsAs 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.
  47. 47. To Reach A DocumentedConclusion or Diagnosis g
  48. 48. EvaluationsD0120 periodicD0140 limitedD0145 under 3 years of ageD0150 comprehensiveD0160 d t il d and extensive, detailed d t i– by reportD0170 re-evaluation – limited re-D0180 comprehensive periodontal
  49. 49. Periodic Oral EvaluationAn 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.
  50. 50. 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 throughhadditional diagnostic p g procedures. Report additional diagnostic procedures separately.
  51. 51. Limited Oral EvaluationAn 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.
  52. 52. Problem FocusedTypically,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..
  53. 53. Comprehensive Oral EvaluationUsed by a general dentist and/or aspecialist when evaluating a patient i li t h l ti ti t comprehensively. It is a thorough evaluation and recording of thee t ao a and t ao a a d and softextraoral a d intraoral hard a d so t tissues.
  54. 54. ComprehensiveThis includes an evaluation for oral cancer where indicated, the evaluation and recording of th l ti d di f thepatient’s dental and medical history and a general health assessment.
  55. 55. Comprehensive It may include the evaluation andrecording of dental caries, missing orunerupted teeth restorations existing teeth, restorations, prostheses, occlusal relationships, periodontal conditions (including periodontal charting), hard and soft tissue anomalies, etc anomalies etc.
  56. 56. Detailed and ExtensiveA 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.
  57. 57. Detailed and Extensive Integration of more extensive diagnostic modalities to develop atreatment plan for a specific problemt t t l f ifi bl is required. The condition requiring this type of evaluation should be described and documented.
  58. 58. 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..
  59. 59. D0170 Re- Re-evaluation - limited, problem focused Established ti t E t bli h d patient; not post-operative visit. p post- pAssessing the status of a previously existing condition. condition
  60. 60. What are the global aspect ofthe procedure and condition?
  61. 61. ComprehensivePeriodontal Evaluation New or established patientsshowing signs or symptoms ofperiodontal disease and for the patients with risk factors such as smoking or di b t ki diabetes.
  62. 62. D0180It 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
  63. 63. D0180It may include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, restorations occlusal relationships and oral cancer evaluation. l ti
  64. 64. How Often Can ICharge For A New Comprehensive Evaluation? How about the new or established patient? t bli h d ti t?
  65. 65. 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
  66. 66. What About OfficeVisits and That New Code For Case Presentations Can we charge for those?
  67. 67. Professional VisitsD9430 office visit for observation (during regular scheduled hours) – no other services performedD9440 office visit – after regularly g y scheduled hoursD9450 case presentation, detailed presentation and extensive treatment planning
  68. 68. Radiographs and Diagnostic Imaging
  69. 69. New For 2013D0391 interpretation of diagnostic imageby a practitioner not associated with thecapture 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”
  70. 70. Radiographic Frequency?Complete S iC l t SeriesTwo BitewingsFour BitewingsPanoramic Film
  71. 71. Don’t Schedule Based On TheDon’ Calendar or Benefit Plan
  72. 72. 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.”
  73. 73. ADA Council on Scientific Affairs “Routine use of “The nature and extentradiography as part of of the diagnosisperiodic 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…
  74. 74. “Radiographs Are Not To g pBe Taken Until The DoctorsHands Or Eyes HH 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
  75. 75. Diagnostic ImagingD0350 oral/facial photographicimages – 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
  76. 76. New for 2013 Coding Cone BeamLess than one whole jawOne full dental arch – mandibleOne full dental arch – maxilla– With or without craniumTMJ series With and Without Interpretation
  77. 77. Tests and Laboratory ExaminationsD0425 caries susceptibility tests– not to be used for carious d ti staining tt b df i dentin t i iD0460 pulp vitality tests– Includes multiple teeth and contralateral comparison(s), as p ( ) indicated.D0470 diagnostic casts
  78. 78. Miscellaneous ServicesD9950 occlusion analysis – mountedcase– Includes, but is not limited to, facebow, interocclusal records tracings, and diagnostic wax-up; for wax- diagnostic casts see D0470 casts,
  79. 79. What is a (brush) biopsy?
  80. 80. Other Surgical ProceduresD7286 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.
  81. 81. with CDT-2005 CDT 2005D7288 was the new codenumber and the descriptorwas simply changed from py gCytology to Transepithelial Sample Collection
  82. 82. 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 proceduresThis is the code number for most of the other oral cancer screening techniques
  83. 83. PreventiveHow do you get paid for a two visit prophy? p p y
  84. 84. Prophylaxis - AdultA dental prophylaxis performed on transitional or permanent dentition which includes scaling and polishing procedures to remove coronal plaque, calculus and stains. t i
  85. 85. 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
  86. 86. 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
  87. 87. Let’s Do Some ClaimsLet’
  88. 88. DoctorD t Clinical Cli i lDiagnosis Findings Code Narrative / Attachment
  89. 89. •No attachment loss No •No bone loss •Abundance of plaque, calculus and stain “Last f i “L t professionallD1110 Prophylaxis cleaning was 24 months ago” ago
  90. 90. 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
  91. 91. Fluoride TreatmentPrescription 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
  92. 92. Topical Application TreatmentD1206 fluoride varnishD1208 fluoride Deleted in 2013 were D1203 and D1204
  93. 93. D1120Prophylaxis - ChildRefers to a (routine) dental ( ) prophylaxis performed on primary or t i transitional iti l dentition only. y
  94. 94. If The DentalAssistant Does TheCoronal Polishing, g,What Code Number Do We Use? Is it a prophy?
  95. 95. OOther Preventive S ServicesD1330 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
  96. 96. Preventive or Restorative?How about air abrasion?
  97. 97. Other Preventive ServicesD1351 sealant - per tooth– Mechanically and/or chemically prepared enamel surface sealed to p prevent decay. y
  98. 98. with CDT-4 was added CDT-D2391 resin-based composite resin- -one surface posterior pUsed 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.
  99. 99. Sealant – per tooth“Mechanically and/or chemically prepared enamel surface sealed to prevent decay” decay”These are not preventive resin p restorations
  100. 100. D1352preventive 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
  101. 101. RestorativeWhat code numbers identify the new generation of hybrid restorative materials?
  102. 102. with CDT-4 was added CDT-“Local anesthesia is considered to be part of restorative procedure”
  103. 103. since CDT-2005 CDT- Descriptor reads“Local anesthesia is usually Local considered to be part of the restorative procedure”
  104. 104. What about Anesthesia?D9210 local not in conjunction with joperative or surgical procedureD9211 regional bl k i l blockD9212 trigeminal division blockD9215 local in conjunction with joperative or surgical procedure
  105. 105. What About Nitrous?D9230 inhalation ofnitrous oxide / anxiolysis anxiolysis,analgesia
  106. 106. Amalgam Restorations Tooth preparation all adhesives preparation,(including amalgam bonding agents),liners and bli 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) )
  107. 107. Primary or Permanent AmalgamD2140 one surfaceD2150 two surfacesD2160 three surfacesD2161 four or more surfaces f f
  108. 108. Identification of SurfacesMesial toward the middleDistal away from the middleLingualLi l facing the tongue f i th tBuccal facing the cheekOcclusal chewing surface of posteriorIncisal cutting surface of anterior
  109. 109. 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..
  110. 110. Resin RestorationsTooth 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,
  111. 111. New Generation Restorative MaterialsSinfony®Targis®Targis/Vectris/Ribbond®T i /V t i /Ribb dBellglass HP®Cristobal+® RESIN RESTORATIONS
  112. 112. New Generation Restorative MaterialsProcera AllCeram®In-Ceram ®In-Cera Glass ®Cera-C -GlIPS Empress ®IPS Eris E2 ® PORCELAIN/CERAMIC
  113. 113. Porcelain / ceramic refers t P l i i f to those non-metal, non-resin non- non-inorganic refractory compoundsprocessed at high temperatures (600°C / 1112°F and above) (600° 1112°and pressed, polished or milled – including porcelains, glasses and glass – ceramics ceramics.
  114. 114. New in 2013 e 0 3 Porcelain / CeramicRefers to pressed, fired, polished or milledmaterials containing “predominantly” predominantly”inorganic refractory compounds including g y p gporcelains, glasses, ceramics and glassceramics
  115. 115. Resin refers to any resin –based composite, including p , gfiber or ceramic reinforced polymer compound
  116. 116. 1100 degree rule
  117. 117. Inlay / Onlay MetallicD2510 inlay - one surfaceD2520 inlay - two surfacesD2530 inlay three or more surfaces i l - th fD2542 onlay - two surfacesD2543 onlay - three surfacesD2544 onlay - four or more surfaces
  118. 118. Inlay / Onlay Porcelain - CeramicD2610 inlay - one surfaceD2620 inlay - two surfacesD2630 inlay three or more surfaces i l - th fD2642 onlay - two surfacesD2643 onlay - three surfacesD2644 onlay - four or more surfaces
  119. 119. Inlay / Onlay Resin- Resin-Based CompositeD2650 inlay - one surfaceD2651 inlay - two surfacesD2652 inlay three or more surfaces i l - th fD2662 onlay - two surfacesD2663 onlay - three surfacesD2664 onlay - four or more surfaces
  120. 120. Resin based compositeinlays/onlays must utilize y y indirect technique.Is it laboratory processed? What about CEREC and LAVA?
  121. 121. Noble Metal Contenthigh noble - Gold Palladium, and/or Gold, PalladiumPlatinum 60% (with at least 40% Au)noble - Gold, Palladium, and/orPlatinum 25%predominantly base - Gold,Palladium, and/or Platinum < 25%Palladium
  122. 122. Sorry, SorryTitanium i not aTit i is t noble metal Atomic number 22 Atomic At i weight 47 9 i ht 47.9
  123. 123. with CDT-4 was added CDT-separate classification t l ifi tiTitanium and titanium alloys ( 85%) ll (>85%)
  124. 124. www.IDENTALLOY.orgwww IDENTALLOY org
  125. 125. 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
  126. 126. New in 2013 D2940 protective restorationDirect 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.
  127. 127. Other Restorative ServicesD2950 core buildup including any buildup,pins– Refers to building up of anatomical crown when restorative crown will be placed, whether or not pins are usedD2951 pin retention - per tooth, inaddition t restoration dditi to t ti
  128. 128. with CDT-4 was added CDT- A material i placed i th t th t i l is l d in the toothpreparation for a crown when there is insufficient t th strength and i i ffi i t tooth t th dretention for the crown procedure. This h ld t be Thi should not b reported when t d hthe procedure only involves a filler to eliminate any undercut, boxform, or concave irregularity in the preparation.
  129. 129. Your ClinicalDocumentation Must Confirm50% or > loss of coronal tooth structure and not a full 2-3 mm 2-collar of sound tooth structure at the gingival margin
  130. 130. Post and CoreD2952 post and core in addition tocrown, indirectly fabricated – post and core are custom fabricated as a single unit.D2954 prefabricated post and core inaddition to crown – Core is built around a prefabricated post. This procedure includes the core material.
  131. 131. Additional PostsD2953 each additional indirectlyfabricated post – same tooth p– to be used with 02952D2957 each additional prefabricatedpost – same tooth– to be used with 02954
  132. 132. 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
  133. 133. D2799 provisional crownThis 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.
  134. 134. Now in 2013D2799 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
  135. 135. Other Restorative ServicesD2970 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-
  136. 136. New in 2013D2929 prefabricated porcelain / ceramiccrown – primary toothD2990 resin infiltration of incipientsmooth 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
  137. 137. Redefined with 2013D2955 post removal (not in conjunctionwith endodontic therapy)D2980 crown repair necessitated byrestorative material failureD2981 inlay repairD2982 onlay repairD2983 veneer repair
  138. 138. Other Restorative ServicesD2980 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.
  139. 139. Plan Provisions90th PercentileAlternate BenefitCoordination of BenefitMaintenance of BenefitNon duplication of BenefitDate of Incurred LiabilityBirthday RulePredetermination
  140. 140. Benefit Plan Provisions Must BeConfirmed With EachNew Series Of Visits
  141. 141. Your office must follow the benefit plan provisions provisions.Providership is not a consideration or excuse. excuse
  142. 142. Even if you are not a designated plan provider, provider you must still follow the rules
  143. 143. Secure Specifics In Writing From The gPlan Or Make Other Financial Arrangements. Arrangements Get The Benefit Booklet From The Patient – The www or Fax Back
  144. 144. Always C fi Eli ibilitAl Confirm EligibilityWith Each Appointment If you file the claim, it’s your responsibilit it’ o r responsibility
  145. 145. EligibilityBenefit CardCall the day of the patient visitReference #Name of contactDon’t forget the employerDon’Web based plan access
  146. 146. How and how much the plan pays
  147. 147. What is the 90thpercentile and how isp it computed? p
  148. 148. SurchargeThe stated dollar amount paid to thedentist by the beneficiary, in additionto tht other reimbursements received b i b t i d by the third-party payer(s) third-
  149. 149. 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 thplan with respect to payment for such services, but does not necessarilyrepresent the dentist’s full fee for that p dentist’ service.
  150. 150. Maximum AllowanceThe 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’
  151. 151. Prevailing FeeTerm used by some dental benefitorganizations 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
  152. 152. But what fee goeson the claim form?Your full “USUAL” fee USUAL” We will talk about discounts later
  153. 153. Alternate Benefit A provision in a dental plancontract 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
  154. 154. with alternate benefit The plan is not dictating treatment, they are only , y ydetermining coverage based upon that plans specific contract language g g
  155. 155. Why the plan does not pay? Exclusions, limitations and carve outs of coverage
  156. 156. 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
  157. 157. Maintenance of BenefitsA method of restricting benefitspayable under more than one planSecondary plan pays no more than ifit were primaryIf primary plan pays, secondary plandoes not
  158. 158. Nonduplication of BenefitsA method of restricting benefitspayable under more than one planIf primary plan pays, secondary plandoes notIf primary plan does not pay,secondary plan may/may not
  159. 159. The ProblemElimination and/or reduction of secondary coverages y g although premiums paid by both primary and secondary beneficiaries
  160. 160. The SolutionDon’t accept authorization forDon’payment on secondary coverageHave the plan reimburse the patientFinancial arrangements based onprimary coverage
  161. 161. Rules of PrimacyThe plan covering the patient asanything other than a dependent isprimary iThe plan without a COB p p provision isprimaryLowest dollar threshold is primary
  162. 162. What is the date of incurred liability
  163. 163. 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
  164. 164. The payer has the p y right to ask the g p provider Prep Date Impression Date Seat D t S t Date
  165. 165. With most all benefitpplans, services are not payable or p y reimbursable untilthey are completed y p Make this work in your favor
  166. 166. Assignment of BenefitsA procedure whereby a beneficiary authorizes the administrator of the program to forward payment for covered procedures directly to the treating dentist.
  167. 167. Assignment ofBenefits is not anAuthorization for Payment P t
  168. 168. Primacy of coverage withdependent children Birthday Rule Effective D t R l Eff ti Date Rule Gender Rule
  169. 169. Birthday RuleThe primary payer is determined by the birth date of the insured parentsFirst in the calendar year is primary
  170. 170. Effective Date RuleThe primary payer is determined by the parent whose policy has the oldest effective date
  171. 171. Gender RuleThe primary payer of benefits is father’ p the father’s plan
  172. 172. Extended Families
  173. 173. Preauthorization PrecertificationPredeterminationPrior Authorization
  174. 174. 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
  175. 175. simply defined as: an indication of the dollaramount to be paid for covered p services contingent upon continuing eligibility
  176. 176. 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.
  177. 177. Second InstanceSince we have no record of having received a predetermination… Treatment plan exceeded $250 Benefits are payable for onlydiagnostic,diagnostic preventive and palliative services
  178. 178. Third InstanceUncooperative patient with no printed benefit information“I have insurance and my husband has insurance. Everything is paid at 100% in full”
  179. 179. Never a guaranteeof reimbursement You can’t take it to the can’ bank
  180. 180. DiscountsTotal Fee Charged (Question 53) must bethe fee you intend to collect.It is illegal to discount based on theppatients co-payment. co-p yDiscount must be disclosed when theclaim is filed filed.
  181. 181. OverpaymentsEligibility Confirmed ImmediatelyPrior to treatment?Coordination of benefits?Payer Fraud?Payer Error?Utilization Review?
  182. 182. We are responsible pfor submitting timelyand accurate claims Therefore, we must keep the system simple
  183. 183. EndodonticWe started a root canal and the patient did not return. How do we get paid?
  184. 184. Pulp CapD3110 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
  185. 185. Pulp CapD3120 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
  186. 186. Pulp Capping procedure codes are not identifyingcement bases or cavity liners. They are simply part of the final restoration
  187. 187. 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
  188. 188. D3221 pulpectomypulpal 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
  189. 189. with CDT-4 was added CDT-“This procedure is not to be used when endodontic treatment is completed on the same day”
  190. 190. Endodontic Therapy Pulpectomy is part of root canaltherapy. 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
  191. 191. Endodontic TherapyD3310 anterior– Excluding final restorationD3320 bicuspid– Excluding final restorationD3330 molar– Excluding final restoration
  192. 192. 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
  193. 193. Endodontic RetreatmentD3346 anteriorD3347 bicuspidD3348 molar– The post removal is now unbundled from the global procedure– Submit with treatment notes by report y p
  194. 194. 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– traumaHow was it retreated?
  195. 195. Endodontic TherapyD3332 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
  196. 196. 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
  197. 197. D3354 – pulpal regenerationIncludes removal of intra-canal medication intra-and procedures necessary to regeneratecontinued root development andnecessary radiographs.This procedure includes placement of aseal at the coronal portion of the root canalsystem.systemConventional root canal treatment is notperformed. f d
  198. 198. Apexification / RecalcificationD3351 initial visitD3352 interim medication replacementD3353 final visit– includes completed root canal therapy
  199. 199. Other Endodontic ProceduresD3999 unspecified endodonticprocedure, by reportprocedure– Used for procedure which is not p adequately described by a code. Describe procedure.
  200. 200. PeriodontalHow do you sequence the coding of non-surgical periodontal non- treatment for maximum reimbursement?
  201. 201. ICD- ICD-10 vs. SNODENT SystematizedNomenclature of Dentistry
  202. 202. Annals of Periodontology, Volume 4, 1999I.I Gingival DiseasesII. Chronic PeriodontitisIII. Aggressive PeriodontitisIV.IV Periodontitis as a Manifestation of Systemic Diseases
  203. 203. Annals of Periodontology, Volume 4, 1999V.V Necrotizing P i d t l Di N ti i Periodontal DiseasesVI. Abscesses of the PeriodontiumVII. Periodontitis associated with Endodontic LesionsVIII. Development of Acquired Deformities and Conditions
  204. 204. Periodontal Case Types What is being treated?In what anatomic area is hat it being treated? g
  205. 205. Gingival Disease Inflammation of the gingivacharacterized clinically by changes incolor, gingival f l i i l form, position, surface iti f appearance, and presence of bleeding and or exudate
  206. 206. Early Periodontitis Progression of the gingivalinflammation into deeper periodontal structures and alveolar b t t d l l bone crest, twith slight bone loss. There is usually a slight loss of connective tissue attachment and alveolar bone
  207. 207. Moderate Periodontitis A more advanced stage of the abovecondition, with increased destruction of the periodontal structure and noticeable lossof bone support, possibly accompanied by an increase in tooth mobility There may mobility. be furcation involvement in multi-rooted multi- teeth
  208. 208. Advanced PeriodontitisFurther 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
  209. 209. Refractory PeriodontitisIncludes those patients with multiple disease sites which continue to demonstrate attachment loss after appropriate therapy. These sitespresumably continue to be infected byperiodontal pathogens no matter how thorough or frequent the treatment provided
  210. 210. Anatomic Area Being Treated?Per ToothPer SitePer Sit Per QuadrantP Site -P Q d tPer QuadrantPer ArchPer M thP Mouth
  211. 211. Areas of the Oral Cavity00 entire oral cavity ti l it01 maxillary arch y02 mandibular arch10 upper right quadrant20 upper left quadrant30 lower left quadrant40 lower right quadrant
  212. 212. Gingivectomy / Gingivoplasty It is performed to eliminate suprabony pockets or to restorenormal architecture when gingivalenlargements or asymmetrical orunaesthetic topography is evident with normal b ith l bony configurations fi ti
  213. 213. Surgical ServicesD4210 gingivectomy or gingivoplasty– Four or more contiguous teeth or bounded teeth spaces per quadD4211 gingivectomy or gingivoplasty– One to three teeth per quad teeth,
  214. 214. New for 2013D4212 gingivectomy or gingivoplasty toallow access for restorative procedure,– per tooth
  215. 215. Surgical ServicesD4230 anatomical crown exposure– four or more contiguous teeth– per quadrant d tD4231 anatomical crown exposure– one to three teeth– per quadrant
  216. 216. Surgical ServicesD4249 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.
  217. 217. Clinical Crown LengtheningThis procedure is employed to allow restorative procedure or crown withlittlelittl 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...
  218. 218. Surgical ServicesD4260 osseous surgery– including flap entry and closure– four or more bounded teeth spaces per quadrantModifies the bony support of the teeth byreshaping the alveolar process to achievephysiologic form. Procedure must include the removal of supporting bone.
  219. 219. Scaling and Root PlaningInvolves 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.
  220. 220. Scaling and Root PlaningRoot 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.
  221. 221. Adjunctive Periodontal Services D4341 scaling and root planing – Four or more teeth per quadrant Some soft tissue removal occurs.
  222. 222. What about the patient who needonly limited scaling and root planing? What code number do we use?
  223. 223. Adjunctive Periodontal Services D4342 scaling and root planing – one to three teeth per quadrant Some soft tissue removal occurs.
  224. 224. Non- Non-Surgical Periodontal ServiceD4355 full mouth debridementtot enable comprehensive bl h ievaluation and diagnosis g
  225. 225. D4355 The gross removal of plaqueand calculus that interfere with the ability of the dentist toperform a comprehensive oral evaluation. l i This preliminary proceduredoes not preclude the need for additional procedures procedures.
  226. 226. D4355 When an evaluation evaluation, diagnosis and radiographs are not possible.NotN t a routine procedure ti d
  227. 227. “Gross scalingwithout root planing is no more than prophylaxis” prophylaxis” JADA, March 1987
  228. 228. Adjunctive Periodontal j ServicesD4381 localized delivery of yantimicrobial agents via acontrolled release vehicle intodiseased crevicular tissue,– per t th tooth– by report y p
  229. 229. D4381 redefined 38 ede ed FDA approved subgingival delivery devices containing antimicrobial medications are inserted into the periodontal pockets to suppress thepathogenic microbiota. These devices microbiota slowly release the pharmacological agents so they can remain at theintended site of action in a therapeutic concentration for a length of time. t ti f l th f ti
  230. 230. Forget about the trade name of the product Tell the payer about the drug, drug its concentration and dosage
  231. 231. Other Periodontal ServicesD4910 periodontal maintenanceprocedures (following active therapy)This procedure is for p p patients who have previously been treated for periodontal disease disease.
  232. 232. D4910This 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, forthe life of the dentition or any implant replacement. p
  233. 233. D4910 IncludesRemoval of the bacterial plaque andcalculus from supragingival andsubgingival regions b i i l iSite specific scaling and root p p g planing gwhere indicated (D4341 or D4342) andpolishing of the teeth (D1110).
  234. 234. Wh t b t th What about the evaluation? Is it charged out separately?Can the hygienist do the evaluation?
  235. 235. “Periodic maintenance i t treatment following t t t f ll iperiodontal therapy isnot synonymous with a prophylaxis” prophylaxis”
  236. 236. Never alternate N lt tD4910 with D1110
  237. 237. Sequential Order of TreatmentDiagnose FirstTreat based on diagnosisEvaluate treatmentContinue treatmentContinue evaluation
  238. 238. Questions?
  239. 239. Complete DenturesD5110 maxillaryD5120 mandibularD5130 immediate maxillaryD5140 immediate mandibularD5810 interim maxillaryD5811 interim mandibularD5860 overdenture – complete, by report p , y p
  240. 240. Partial DenturesD5211 maxillary resin base yD5212 mandibular resin baseD5213 maxillary cast metal w/resin b ill l / i baseD5214 mandibular cast metal w/ baseD5225 maxillary w/ flexible baseD5226 5 6 mandibular w/ flexible base a d bu a / e b eD5861 overdenture – partial, by report
  241. 241. Removable ProstheticsAdjustments to DenturesRepairs to DenturesRepairs to Partial DenturesDenture Rebase ProceduresDenture Reline Procedures
  242. 242. New in CDT 2011-2012 2011-D5993 maintenance andcleaning of a maxillofacial gprosthesis (extra or intraoral)other than requiredadjustments, by report j , y p
  243. 243. ImplantsThe surgeon placed the implant and we did the prosthesis. Who codes for what?
  244. 244. D6010 Surgical placement of implant body: endosteal implantIncludes second stage surgery and placement of healing cap
  245. 245. deleted code D6020Abutment placement orsubstitution: endosteal implant An abutment is placed to permit fabrication of a dental prosthesis. p This procedure may include theremoval of a temporary healing capor replacement with an abutment of alternate design design.
  246. 246. Implant AbutmentsD6056 prefabricated –– includes modification and placement– Modification of a prefabricated abutment may be necessary
  247. 247. Implant AbutmentsD6057 custom fabricated– includes placement– created by a laboratory process, specific for an individual application
  248. 248. New for 2013D6051 interim abutment– Includes placement and removal– A healing cap is not an interim abutmentD6104 bbone graft at time of implant ft t ti fi l tplacement
  249. 249. Implant Supported ProstheticsD6053 D6062 D6067 D6073D6054 D6063 D6068 D6074D6058 D6064 D6069 D6194D6059 D6094 D6070 D6075D6060 D6065 D6071 D6076D6061 D6066 D6072 D6077
  250. 250. New in CDT 2011-2012 2011-D6254 interim ponticD6795 interim retainer crownUsedU 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.
  251. 251. Peace at Last
  252. 252. Snoring AppliancesD5999 unspecified maxillofacialprosthesis, by report physician referral copy of sleep study showing confirmed di fi d diagnosis i
  253. 253. Is it a medical liability or a dental d t l p prosthesis?Let the plans decide so the patient can pay the bill
  254. 254. ExtractionsIncludes Local Anesthesia Anesthesia, Suturing, If Needed, and g, ,Routine Postoperative Care
  255. 255. ExtractionsD7111 coronal remnants –deciduous tooth – soft tissue retained coronal remnantsD7140 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
  256. 256. Surgical ExtractionsRedefined in CDT 2011-2012 2011-D7210 surgical removal of eruptedtooth requiring removal of boneand/or sectioning of tooth, and d/ ti i f t th dincluding elevation of mucoperiostealflap if indicated– Includes cutting of g g g gingiva and bone,, removal to tooth structure, minor smoothing of socket bone and closure g
  257. 257. New in CDT 2011-2012 2011-D7251 coronectomy – intentionalpartial tooth removalIntentional partial tooth removal is performed when a neurovascular complication is likely if the entire impacted tooth is removed removed.
  258. 258. AdjunctiveWhy aren’t we being paidWh aren’ efor palliative procedures?
  259. 259. D9110Palliative (emergency ) treatment ofdental pain - minor procedure This is typically reported on a “per visit” basis for emergency treatment g y of dental pain
  260. 260. AdjunctiveWhen is a narrative report or supplemental attachment necessary?
  261. 261. Are We Now Ready To Get The Correct Information To The PatientsInsurance Company? p y
  262. 262. 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
  263. 263. Send all of your claims andattachments electronically
  264. 264. Electronic Claims and AttachmentsPractice Management SystemElectronic Claims Vendorwww. Based All Payer - PlayerFreedom of ChoiceBeware the Unethical BillingService
  265. 265. What aboutsignature on fil ? i t file?
  266. 266. Coding and g ReimbursementManagement is Simple Follow Tom’s Tom’ Seven Keys to Reimbursement Success
  267. 267. Rule 1Diagnose and document prior to initiating any treatment
  268. 268. Rule 2 Establish a writtentreatment plan for the patient as well as y yourself
  269. 269. Rule 3 Secure financialarrangements prior to treatment
  270. 270. Rule 4Patient must acknowledge and agree to pay the total fee prior to insurance consideration
  271. 271. Rule 5Bill and code for exactly what services are rendered
  272. 272. Rule 6What the insurance does not pay - the patient must pay
  273. 273. Rule 7If the patient does not pay - hunt them down like you would a rabid dog
  274. 274. Thank You For Joining Us Please Drive Safely and Courteously C t l