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Coding Pitfalls by Dr. Travis Campbell

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Categories: Practice Management, HR and Accounting;
Coding Pitfalls 

Making sure coding aligns with lab cases and fees

by Dr. Travis Campbell

Without realizing it, a simple disconnect can occur between the lab cases and fees or codes that are billed to a patient and the codes submitted on the insurance claim. When discrepancies in coding occur, it can expose an office to audit challenges as well as profitability concerns. It is important that doctors and team members ensure that coding used for insurance claims matches what is being sent, received, and billed by the lab. Here are some common mis-coding scenarios to always double-check.


Crown materials
There are several different codes for crowns and bridges based on the material used. A change in plan is the most common coding error since the type of material planned for treatment may not always be the material used, because of what is determined to be best during the treatment process itself. It is helpful to confirm the material actually used after treatment, and ensure the correct code is used on the claim form when finishing the prep appointment and lab script.


Dentures
This is typically the largest financial mistake which can occur, as dentists aren’t always aware of how labs bill for services. For example:
  • Flippers: From the lab’s perspective, flippers usually involve one or two teeth for pricing. When more teeth are required, the lab will typically charge a higher fee. When ordering a flipper or acrylic denture, make sure your claim coding and pricing match. A flipper of one to four teeth may be considered an interim partial denture (D5820/D5821), while more than four teeth may more accurately be a resin-based partial denture (D5211/D5212) with a higher fee.
  • Adding teeth to partials: When the lab adds a tooth to a partial denture, sometimes they can simply add acrylic and the tooth, resulting in a lower lab bill. However, if the lab must add to the metal framework, laser welding is required, significantly increasing the cost. In this case, the procedure becomes a partial denture repair (D5621/D5622) in addition to D5650 (adding a tooth). Using the combination of codes helps raise the fee enough to cover the additional lab cost. What was initially ordered may need to change during the lab process, impacting both the fee charged and the claim coding required.
Keep in mind that insurance will only reimburse for one denture code. Know this when estimating for patients.

Alternatively, a dentist could instruct the lab never to add metal, which keeps costs down. If the unsupported resin breaks around the new tooth, creating a new partial denture would be the next step.


Implant screw-retained crowns
The most common misconception around coding—even among experts—is how to code a screw-retained crown. This confusion stems from the description in the ADA coding companion, which incorrectly claims a screw-retained crown is an implant-retained restoration.

The problem here is that the ADA codes are intended to only report what was done, not to define the clinical procedures that dentists do and do not perform. The misunderstanding is, a screw-retained implant crown has an abutment inside, and the lab charges the office for that abutment. Since the lab charges for the abutment, the only way to code is by coding an abutment; to do otherwise would be considered fraud. The golden rule in coding is to always report what was done.

Coding does not change between a screw-retained or cement-retained crown, as both require an abutment. Therefore, always use an abutment-supported restoration code (D6058–D6064) for either situation, along with an abutment code (D6056/D6057).

An implant-retained restoration (D6065/D6067 and D6082/D6088) is one in which the implant and abutment are a single fused piece of metal, which are often termed as miniature implants with no screw access.

Any type of screw access in an implant means an abutment must be placed into that access, and therefore an abutment must be coded (D6056/D6057) to follow the golden rule.

The financial impact is that an implant-retained crown code is far less expensive than an abutment and abutment-retained restoration. The lower-cost option only makes sense if the implant allows a crown to be cemented directly to it, which is the only time the lab would not charge the dentist for the abutment connector.


Overall
As you can see, there are multiple ways in which incorrect coding can cause challenges both in audits and with financial implications for the office. Ensuring the claim code matches the actual service provided helps keep an office both compliant and financially stable.
Author Bio
Author Dr. Travis Campbell is a practicing dentist and multiple-practice owner who lives in Prosper, Texas, with his wife and two young children. Having gained a reputation as an expert in the complex area of dental insurance, Campbell is commonly known as “The Dental Insurance Guy!” He dispels many of the myths and misinformation surrounding today’s dental insurance policies and explains how to navigate the complexities of being an exceptional dentist, business owner, and leader, while still having a life outside of work. His most recent textbook, Understanding Dental Insurance, has become a bestseller in dentistry and has already sold out twice. He has also launched the most comprehensive online resource for dental insurance: dentalinsuranceguy.com.
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