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Cracking The Codes, Part 2: Restorative Reimbursements by Dr. Dominique Fufidio, FAGD

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Categories: Practice Management, HR and Accounting;
Cracking The Codes, Part 2: Restorative Reimbursements 

Narratives and the right photography improve insurance acceptance for indirect restorations and restorative foundations

by Dr. Dominique Fufidio, FAGD

Part 1: SRP
In Part 1 of this series, Dr. Dominique Fufidio, FAGD, covered how to improve your chances for insurance reimbursements for scaling and root planing procedures. To catch up, click the link here.
When it comes to indirect restorations—specifically crowns and onlays (if the policy will cover onlay treatment) and the restorative foundation of a core buildup—most dental practitioners and patients seem to believe that insurance carriers just don’t want to pay these benefits. This is not true; third-party payers are more than willing to reimburse insurance benefits for treatment that should be benefited. But which procedures or situations qualify to be benefited?

Like any business, including your own dental practice, insurance companies have standard policies to determine if a service meets the criteria to be paid for treatment rendered. This isn’t reinforcing or passing judgment on your treatment recommendation—it’s making a clinical claim decision about whether the treatment was medically necessary at the time it was rendered. Let’s review specific criteria common to most insurance carriers (although it may vary slightly from specific payer to payer).

Preoperative images
When a clinical claim review is performed for an indirect restoration such as a crown or onlay, a preoperative radiograph is generally required. This is an X-ray, not merely a photo.

Some carriers require this radiographic image be periapical and capture the entire apex, so confirmation can be made that the apical region is free of pathology or is being treated appropriately. Capturing the entire root length and clinical crown can be a challenge, but the clinical crown also needs evaluation to demonstrate the condition of the coronal structure before treatment. (Some carriers will accept a bitewing radiograph without a periapical radiograph and others will not, but for most practitioners, your standard of care is to have a quality PA, so this is not an issue.)

After endodontic treatment, a PA is typically acquired or provided to confirm a successful obturation and root canal treatment, but offices are typically surprised to discover that an intraoperative image isn’t needed for the submitted claim to be reviewed.

If a crown is dislodged and a PA was acquired before refining a prep or registering an impression/scan of the tooth, be sure to communicate that the image is a preoperative radiograph, not intraoperative. Many offices provide intraoperative photos to demonstrate they did the prep, but the insurance carrier isn’t looking to confirm treatment was done; the payer is trying to evaluate whether the treatment was medically necessary. If a filling is removed and a photo of the final prep shows little remaining tooth structure, a clinical claim reviewer can’t tell if that was because of an overzealous preparation design or if decay extended as far as the photo captures.

If you plan to submit intraoperative images, take a full series of photos. This way, you can demonstrate the preoperative condition, decay as it is being excavated, and the final preparation with the little remaining tooth structure. Label and highlight these images if there’s something specific you don’t want the reviewer to overlook, but I think a well-written narrative takes half the time and is often more successful during claims review because the consulting dentists aren’t trying to orient themselves to a photograph or consider what happened during the appointment. A narrative describes it. Is a cusp lost? Document it in the narrative, and add a photo if you choose. Is there a crack in the tooth that is symptomatic and you tested it, or does this fracture or crack extend to the pulpal floor? Document it in the narrative, along with a photo if you choose.

Treatment narratives
Let’s talk more about narratives. Photos can be useful, but I highly recommend that details of the treatment and diagnosis be documented in a narrative. Technically, a narrative is any additional written information. This can be a single word, a sentence or a page from a novel about the tooth and the patient’s treatment.

If an office is using the American Dental Association’s standard claim form, the narrative is usually submitted in Box 35, but this “Remarks” section has a character limit. Best practice is to submit the narrative as an additional attachment or enclosure so the whole story of the tooth condition and treatment can be relayed and you can bring your supporting photos into your narrative. This is much more extensive than what can be reported in Box 35, and many times the radiograph alone just does not show the complete story of the tooth. Without all the information, medical necessity just cannot be confirmed with conviction.

Some offices submit a copy of a checklist as a narrative. A checklist is a great way to document your findings while chairside, to remind you of the important specifics you need to elaborate on in your clinical progress notes. I used route slips to write findings on and prompt me as a reminder to include in my treatment notes later. My office always wanted to scan my chicken scratch into the patient record, but it was just that—a series of words, phrases and references or anatomical landmarks to remind me to put a complete note together with all of these specifics. I love a checklist, but it’s simply not enough for a powerful, unquestionable, impactful narrative when this information is highly valuable and can overturn an adverse determination.

Stepping out of line(s)
On the list of etiology for an indirect restoration to discuss: wear, attrition, abrasion and abfraction, all with or without sensitivity. Carriers popularly have exclusions for the abovementioned conditions in the absence of dental caries.

When I would do peer-to-peer calls, my peers would say, “But the tooth was sensitive.” When it comes to medical necessity for indirect restorations, sensitivity with no indication of dental decay doesn’t meet most carriers’ criteria. From the insurance perspective, there are different ways to combat sensitivity, so a restoration isn’t the only viable option. Be mindful when restoring worn dentition or restoring lost vertical dimension; although the patient will benefit from treatment, insurance benefits may not be allocated for these services if they’re deemed not medically necessary.

One helpful chairside diagnostic tool for indirect restorative treatment is transillumination. Most of us were taught that if there’s a crack in the tooth, as identified with transillumination, a crown is necessary. I found transillumination tremendously helpful when leveraged as a patient education tool, but many insurance carriers won’t accept transillumination findings, photos or documentation alone as supporting information to the medical necessity for a crown.

An article by Lubisich et al. reported that transillumination is one of the most common methods for crackedtooth identification but also has its drawbacks; for example, transillumination dramatizes all cracks to a point where craze lines may look structural in nature.1

But don’t all cracks need treatment to prevent propagation or fracture, rendering the tooth nonrestorable? There’s ample supporting literature that indicates not all cracks need treatment—a perspective shared by many payers. An article by Mamoun et al., for example, reviews common clinical examples of cracked teeth, including cusp fractures, fractures into furcations and root fractures. The article gives alternative definitions for crack lines and complete and incomplete fractures, among other terminology. A partial fracture was considered restorable and was done to prevent a catastrophic, complete fracture, which would be unrestorable with a direct restoration—but it was reported that not all cracks and craze lines indicated a need for full-coverage restorative treatment.2 So a patient and their specific tooth may benefit from having a full-coverage restoration as a predictable, long-term preventive treatment option, but when dental benefits are allocated for cases of true medical necessity, an asymptomatic tooth with craze lines but no structural cracks does not meet criteria and typically is not benefited.

Building up a successful claim
Let’s conclude with some final thoughts on restorative foundations (core buildups). Reimbursement for indirect restorations such as crowns and onlays is much higher than that for restorative foundations. The ADA Council on Dental Benefit Programs has reported many office complaints around D2950 denials, and payers report it as one of the most commonly abused CDT codes.

The CDT description defines the D2950 treatment as “building up of coronal structure when there is insufficient retention for a separate extracoronal restorative procedure. A core buildup is not a filler to eliminate any undercut, box form, or concave irregularity in a preparation,” but the D2950 is popularly planned and billed in conjunction with almost every crown coming from some offices, or is submitted in cases where the material appears to be more of a filler and not truly placed for crown retention.

Code D2949 more accurately describes this and accounts for the majority of the D2950 denied submissions: “Placement of restorative material to yield a more ideal form, including elimination of undercuts.”3 This appears to be the procedure that’s done more often than the D2950, and benefits can only be allocated for services that match the codes submitted for review.

So would a true core buildup be reimbursed? When is it considered medically necessary? Is there a lost cusp? Is there less than 2 mm of remaining tooth structure for one of the walls of the prep? Is maybe half of the occlusal table missing? These are all cases where documentation will be your friend in having a buildup reimbursed. Include in your narrative which cusp was lost, exactly how much remaining tooth structure there is to which wall, and estimate the amount of the coronal structure and occlusal table lost. Include photos for additional support.

Initially, this criteria may sound frustrating, but by developing a keen awareness of the requirements like the ones described in this article, you’ll have a more predictable claims submission experience and engage in more accurate benefits discussions with your patients.

Remember to treatment-plan as you see fit. These are benefit determinations based off the policies set by the insurance carrier to have an equitable review process, and are largely aligned across all carriers with slight nuances. These are not treatment recommendations—those are yours and yours alone

References
1. Lubisich EB, Hilton TJ, Ferracane J. “Cracked Teeth: A Review of the Literature.” J Esthet Restor Dent. 2010; 22:158–67.
2. Mamoun JS, Napoletano D. “Cracked Tooth Diagnosis and Treatment: An Alternative Paradigm.” Eur J Dent. 2015 Apr–Jun; 9(2):293–303.
3. ADA. CDT Code D2950. “Top 10 Claim Concerns: ADA, NADP Share Views on Dentists’ Concerns” on www.ada.org.

Author Bio
Dr. Dominique Fufidio Dr. Dominique Fufidio, FAGD, is the founder and main coach at Fufidio Consulting Group, where she has pioneered a coaching experience focused on understanding the dental insurance claims review process. She also serves as the director of specialty services for Apex Dental Partners. Previously, Fufidio had been the owner of a successful fee-for-service private practice, a top-performing dental claim reviewer and an artificial intelligence co-creator. She continues to engage with the dental community via writing and speaking. Information: fufidioconsultinggroup.com.
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