Dental Coding Q&A

A patient, who hadn’t been in for a prophy in over 2 years, came into our office the other day for a prophy and exam. Our hygienist took 4-bitewing x-rays and informed me that the patient needed to return for a second prophy and perio charting. She did a cleaning just to remove the severe calculus and some staining. She told me that she had to do a cleaning to be able to chart properly for the next visit.

What code should have been used to bill it out to the insurance company? What code should be used for the follow-up visit? What are other offices doing in these situations? I was planning to use D4355. Full mouth debridement to enable comprehensive periodontal evaluation and diagnosis. Can I also use the same code for the second cleaning?
Official Townie: Happysmile67

A startling way to answer your question is with this question: What is the difference between a prophylaxis and a prophylactic? This leads to an obviously next question...What does prophylaxis mean? Does your insurance form/walkout statement say ‘Adult Prophylaxis’ when you enter code D1110? What would an educated adult in in the year 2001, assume that meant?

You overcame the incorrect and illegal answer of doing multiple ‘preventive procedures’ and intuitively recognized D4355 as the correct first step. The fee for D4355 is double or triple your ‘prophy’ fee, thus you are paid for both of the visits.

Dr. Udel Webb
Is there any recourse we have as a dental provider towards an insurance company that is taking an unusual amount of time in processing claims? In addition to very slow processing, we have experienced the loss of 2 FMX submitted for documentation of procedures that fall within basic standard of care guidelines.

Thank you in advance for the help.
Trish Morris-Plise, RDAEF

Always diagnose before your prescribe. Your question shows symptoms of a bigger pathology at work. Here are some of the diagnostic questions which must be answered before you can prescribe a cure.
1. Are you sure that it is an insurance company?
2. Did you know that Delta Dental, for example, is not an insurance company? Really...they are service corporations.
3. Is it a PPO or other managed care program?
4. Do you have an approved fee or fee schedule with them? (If so, you have joined the PPO and are subject to their rules, without recourse.)
5. Why did you submit radiographs for ‘basic standard of care’ procedures?
6. Why didn’t you use electronic claims, thus obviating radiographs?
7. If you are a ‘dental provider’ you probably joined the club, right? A fee-for-service dentist would have a different set of options, don’t you agree?

If it is the insurance company, which is not highly probable, your ‘recourse’ is with the State Insurance Commissioner for the state in which your practice is located. Discovering the answers to the first six questions is probably the best recourse for eliminating future occurrence of this problem.

Dr. Udel Webb
It is our understanding that waving or discounting patient co-pays while billing insurance companies their full share constitutes insurance fraud and therefore is illegal. However, we regularly see ads, brochures and flyers by dental offices offering huge discounts to first-time patients (which presumably includes those with insurance coverages) for x-rays, exams and prophys. Apparently, this practice is legal...right? If so, how and why?
Merwin Diaz

You’re a bit sneaky...you asked two questions for the price of one. The first question: Waiver of co-pay is illegal. You must represent to the third-party payor the actual amount charged for the service. It can be fairly assumed that you intend, with reasonable and common effort, to collect the entire charged amount.

Huge discounts, are not the same as waving the co-pay. The discounted price, or actual price charged should be reflected accurately on the claim form if you are asking the third party payor to reimburse the patient for that expense. Reporting a charge different than the charge actually made could be considered as fraudulent.

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. His answers are based on 25 years of painstaking research into the dental insurance issues that face our offices. If you seek legal advice, contact your favorite legal expert.

Dr. Webb is a 1976 graduate of Baylor College of Dentistry, Dallas, Texas. Del is married and has seven children. Contact Dr. Webb at: (877) 628-3366