CDT-4, HIPAA, Fees and When Do I Start? By: Udell Webb, DDS, Director, Udell Webb Leadership Institute

Insurance Company Input
Anytime you deal with billions of dollars, many parties have opinions and needs. As one Townie pointed out, the insurance industry does have input into the fee changes. I have a current email from one insurance executive that states he is working on CDT-5 and that it is a pain for them too.

Don’t Get Rejected Because You Used the Old Code
One of the benefits of HIPAA is the ADA codes have been accepted as the final answer. The CDT-4 codes must be recognized by everyone. That does not mean that they have to be paid by everyone. But, they can’t say, “We don’t use that code.” So, use the new CDT-4 codes as your codes.

“It would behoove any dentist to make sure his or her office is brought up to date,” says Dr. Charles Cuttino, former chair of the Council on Dental Benefit Programs. “Carriers are likely to reject old, invalid codes, inviting delays in reimbursements.” Start using the new codes today. Fewer claims will have problems because the new codes were used than will have problems because the old codes were used. The UCR for the new codes will be higher. And soon, under HIPAA, it will be the law.

Now is the Time to Raise the UCR
Another Townie questioned when to start using the new codes. This is your best opportunity to influence the fees for the new codes. Remember, the insurance companies record the fee numbers as submitted by the practitioners on dental claims. They “sell the numbers” to a company, such as the Health Insurance Association of America (HIAA). Since HIAA is not an insurance company, it can compare and analyze fees without worry of restriction of trade litigation. HIAA then ‘’sells” the data back to the insurance companies. The data is broken into percentiles, or “how many doctors in this zip code area are charging this amount?” The 75th and 80th percentiles are the numbers most commonly used by most plans for reimbursement. That’s for non-PPOs. Remember, your submitted fees, the percentile range and the zip code area are the critical factors in determining how much an insurance company will reimburse for a particular plan. I am holding in my hand, as I write this article, dollar amount projections from the insurance industry for the new and modified CDT-4 codes. They had to start somewhere. The new 2003 UCR tables have dollar amounts for the different percentiles, for your zip code area. Please remember, your submitted fees will influence the UCR the most. Do not, as one Townie suggested, use your lower fees. For most of the new fees, the dollar amount appears to be higher, not lower. Use the highest fees you need to allow for profit when costs, care, skill and judgment are considered. Do not underbid anything now.

The New Perio Codes
According to my HIAA-based UCR table, the projected reimbursement amount for the new D0180 is a few dollars more in every percentile level than the dollar amount for code D0150. D0150 is a comprehensive, involved, time sensitive evaluation and the projected reimbursement for code D0180 is higher. In most areas, the UCR for D0160 is 300-500% higher than D0150. D0180 is only very slightly higher.

Use the new root-planing code that allows you to do less than a full quadrant. It is the best new code to come along in the last 50 years! Stop doing a “prophy” on people with current dental disease. (See the November issue of DentalTown Magazine for details). My recommendation is that you use your old quadrant fee for the new partial quadrant and double your old full quadrant fee. Base upon hundreds of offices’ fees, you are probably at about half of the “fair” fee now. The UCR tables bear out this ratio.

Combined Restorative Numbers
The message boards have a lot of opinions on how to handle the new “combined” restorative codes. My opinion, based on inside sources, is that you should not charge the old “pedo, or primary” fees. I could argue all day about why your fees are too low in the first place, but that won’t help here. The answer that I received indicates that most companies will set the computerized reimbursement level at the “permanent” level. The follow-up was that the dentists should not expect rapid increases in the UCR for those codes now for a couple of years.

For Implant & Abutment Supported Full-Denture, Try Medical Insurance
The UCR numbers I have seen for implants and abutment supported full dentures, as well as all other new codes are on the “healthy” side. Many medical policies will, yes will, cover the implant placement and the related radiology, evaluations, etc. That is another form of insurance coverage that many patients have and would love for you to use. For example, if you do four wisdom teeth on that teenager, there is typically no insurance money left for other forms of dentistry. Do the extractions under medical and save the dental insurance for the dentistry. Moms love it!

Udell (Del) Webb, DDS, is a nationally recognized expert in the area of dental insurance management. He is not an attorney, an insurance company employee or licensed by any group or agency to answer insurance-related questions. If you seek legal advice, contact your favorite legal expert. You can contact Dr. Webb at (877) 628-3366.