Many doctors are plugging along year after year without updating their fees, updating their new, revised and deleted CDT code lists or underutilizing certain codes. With the Square Practice software, a doctor, or their business coach, can easily scan the Procedure Code Lists and see which codes may be missing or incorrectly being charged out.
10 Misused or Underutilized Dental Procedure Codes
Each year, dental offices get a list of all the Deleted, Revised, and New CDT codes from the ADA. It is important to not only modify these in your practice management system, but also to notify your team to stop or start using the corrected codes. They should also watch for codes that may have been entered for future visits or previous treatment plans that were changed or updated.
With that in mind, having looked at many dental office’s Procedure Code Utilization Lists, we are providing some commonly misused or unused codes that we have seen so you can also check to see if they are being properly billed out to avoid unnecessary delays and also to maximize your productivity.
D1206 Fluoride Varnish, or D1208 Fluoride
We’ve seen some offices that most children and 80% of the ADULT patients are routinely getting fluoride treatment, and we’ve also seen office that only a dozen patients a year are getting fluoride. While a conversation about the two opposing “camps” on the fluoride controversy, holistic vs health benefits is beyond the scope of this article, it is often covered by many dental insurance plans utilizing code D1206 Fluoride Varnish, or D1208 Fluoride Gel (trays). It can be argued that children with deep grooves in teeth or who don’t brush well, people with radiation therapy, pregnant, diabetics, dry mouth, elderly with exposed roots, people with physical disabilities, and dozens of other conditions, can potentially benefit from this service. (Identifying the patient as high caries risk – using CAMBRA Risk Factors, and letting patients know it may not be a covered benefit can help with acceptance.)
Sealants Code D1351
Sealants are easy to place, can have fluoride release, and can offer protection from tooth decay. Code D1351 can potentially add value to your patient’s oral health preventive program. Billing sealants that don’t go into the tooth as fillings is fraud and this code is generally only used for superficial preventive resins. Many offices are underutilizing this service.
Fit to CROWN Code D2971
When you have a partial denture that fits over a new crown, many offices don’t add the Code D2971 -additional procedures to construct a crown under an existing partial denture framework, to their fee. It takes extra effort and sometimes an extra visit for the lab to get the fit perfect. If you are using a CAD/CAM system such as CEREC in-office, you will find you can scan the crown before and it makes the task of “retro-fitting” the crown easier.
Gross Debridement Code D4355
When a patient comes in with so much plaque, calculus, or staining on their teeth that it interferes with doing a proper initial exam, you may charge out an initial debridement fee. This procedure Code D4355 is a full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit. In other words, you can’t bill out a D0150 Comprehensive exam (or D0160 or D0180) on the same day. [In some instances, a D0191 Assessment of a Patient or a D0140 Limited Oral Evaluation – Problem Focused may be acceptable on the same day for bleeding or painful gums – but this is usually to evaluate pain or infection or emergency.] Typically, this will be a one time per lifetime per plan benefit. One code that sometimes gets confused with this is Code D4346 for moderate to severe GENERALIZED gingivitis beyond a prophylaxis, for a regular patient, who doesn’t need 4 quadrants of SRP. Some plans don’t cover this, but if they do, it might be for about 20% higher rate than your typical prophy fee at best. This is done AFTER an exam is completed and it is considered a therapeutic procedure.
Periodontal Scaling 1-3 Teeth Code D4342
If you have a patient that is missing teeth in a quadrant or only has a few deeper pockets, you should be billing out Code D4342 for 1-3 teeth scale and root planning. If you have two or more quadrants, your next “cleaning” should be a Code D4910 periodontal maintenance. Note that pockets over 3mm or bleeding gums does NOT automatically qualify a patient for SRP. Neither does visible calculus on the tooth. For scaling and debridement in the presence of inflammation or mucositis of a single dental implant, you could use Code D6081.
Antimicrobial Agents Per Tooth Code D4381
Use Code D4381 for the localized delivery of controlled release antimicrobial agents (Atridox®, Actisite-Tetracycline® fiber, Arestin®, or PerioChip® for example) into a periodontal pocket per tooth. It is NOT for Perio Protect® trays for an entire arch, that is Code 5994 per arch, per tray. If you irrigate with Chlorhexidine or other irrigation, use Code 4921 irrigation per quadrant. It is usually wise to include a narrative when submitting to insurance and know often most plans will limit you to 2-3 sites per quadrant IF they pay at all. Note: It is MORE likely to get paid for at the D4910 visit periodontal maintenance, than at the time of or within six weeks following SRP therapy as a way to treat areas that didn’t resolve from the SRP. It may sometimes be covered as an adjunct to the prophylaxis D1110 for isolated pockets.
Occlusal Guards Code D9944
The new Code D9944 for a HARD GUARD (night guard) replacing the prior deleted Code D9940. It is for bruxism and clenching. It is often confused with Code D7880 for a TMD appliance, Code D9946 NTI-type appliance, Code D9975 teeth whitening trays, or the Code D9945 SOFT GUARD – often made in the office. Most plans have limitations and exclusions, so it’s best to get a predetermination of benefits if the patient isn’t onboard paying for the entire cost.
Just because an insurance plan lists a specific code does NOT imply that it is a “covered benefit” of that plan. While it is important for your staff to understand these codes so they can bill accurately, it is the Owner Dentist who will ultimately be responsible for proper implementation and submission.
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Article by Randall LaFrom, D.D.S., CEO of The Dentist Advantage and President of Integrity Dental Marketing.
The Dentist Advantage works with Square Practice's software to provide excellent insights, strategies and coaching for practices at all stages in their career. Contact us today for a Free, no cost or obligation chat about how we may be able to help your practice as well!
Dr. Randy LaFrom
Business Consulting and Practice Strategies.