By Elicia Lupoli, RDH, BSDH

Too often the dental industry complains patients only want what insurance covers and yet these same people will continue to treat patients this way because of their thinking, not the patients’ preferences. Dental hygienists can help bridge this gap through encouraging appropriate CDT coding and medical insurance billing. Here’s a place to start.

“The purpose of the CDT Code is to achieve uniformity, consistency, and specificity in accurately documenting dental treatment. One use of the CDT Code is to provide for the efficient processing of dental claims, and another is to populate an Electronic Health Record.”—The American Dental Assocation (1)

Many dental hygienists are or have transitioned from clinical hygiene into managerial or financial/treatment coordinating positions. These dental hygienists have the power to initiate change and become an active participant of insurance, coding, and billing.

Still, there are many clinicians who have unanswered questions regarding billing protocols. We do not have to be in a position of authority to voice our concerns; nevertheless, it is ideal to be armed with the facts prior to suggesting solutions. Always provide a solution when addressing an issue.

Stop making assumptions

Some dental professionals are trained to think about what insurance benefits cover, treating the insurance and not the patients. This has been a topic of conversation for decades. While many people may have financial difficulties, others do not. How are we to know what a patient has in their bank account? The answer is simple—we do not know.

One major problem in dental settings occurs when the billing coordinator refrains from submitting procedures to the beneficiaries’ insurance company. Specific Codes on Dental Procedures and Nomenclature (CDTs) exist for nearly all procedures, but frequently the person responsible for submission will say, “I know insurance won’t pay anyway.” This is one of the worst administrative mistakes. An example may include an office that does not submit a provided and completed CDT code to the patient’s insurance (e.g., locally applied antibiotics, subgingival irrigation).

The dental team should never assume! If a patient were to find out that their insurance was not billed and they actually did have coverage, how would this be explained? People are more and more tuned into to their health care (thank you, World Wide Web). In addition to being unethical and judgmental, this lack of prudence is insurance fraud, and insurance fraud is a felony!

Another frequent error is to assume that dental care does not require copays and deductibles. Every time we walk into a medical facility, we are asked for money. How many times do we hear the administration team say, “I’ll send you the bill after insurance pays”? Patients often become trained by this behavior, believing it is common practice to receive dental care and pay later.

Narratives and coding
That brings me to another common phrase: “I’ll wait until the claim comes back and if they don’t approve it then I’ll send a narrative.” Not only does this create extra work, but also delays payment to your employer who is the one signing your payroll check. Is that fair to the practice owner who hires and trusts the employee to manage the insurance accurately, legally, and timely? No, it is not. It might take two minutes to write a brief narrative such as, “Patient has third molars. Needed 4bw’s to assess decay and/or impaction.” Insurance consultants want the narrative to be short and simple.

Ask yourself, “If a patient has a full compliment of 32 teeth, will two bitewing radiographs suffice?” Ideally, the clinician will take four and then the person who submits to insurance will include four in the claim with a narrative attached. If the office needs help with narratives, there are wonderful resources out there. Review Coding with Confidence by Charles Blair, DDS, or DentalCodeology Patti DiGangi, RDH, BS, for narratives and insurance help. I can guarantee employers will buy these books if they know it will help their bottom line by increasing insurance payments and reducing denials.

If the procedure is not covered or is downgraded as two bitewings, then the patient must pay. Explain to the patient that a procedure is necessary for diagnostics. If you have a hard time communicating to patients what they need, try to put yourself in their shoes. If you still feel unable to explain, then perhaps they do not need that service in the first place. You can ask to take a class that will enable you to feel more confident while discussing services and treatment options with patients.

Don’t assume all plans are the same

Usually, a dental insurance company does not have the same exact plan for every client. Each individual chooses his or her own plan. While some policies within an insurance carrier may commonly only pay for two (not four) bitewing radiographs a year, like Delta Dental of Illinois, this does not mean every single patient insured with Delta Dental has this restriction. (2) The insured usually has an option to choose a financially feasible plan that best serves his or her needs. An employer that pays for their staff to have dental benefits may pick the plan and essentially that is the only time a group of people may have the same coverage. A lot of schools and city boards have the same dental plans and this is because they are paying for their employees’ health benefits.

Too often the dental industry complains patients only want what insurance covers and yet these same people will continue to treat patients this way because of their thinking, not the patients’ preferences. It is up to each dental office to get on the right path as a team and bill/submit for every single procedure completed no matter what. Dental software programs can provide a report on any procedures not attached to insurance.

Please do not treat your patient according to their presumed coverage; most of them would not want you to do this if you explained the necessity behind the procedure. Consider that “approximately 50% of employees with dental insurance will not use it in any given year.” (3) Are these patients (1) not coming to dental offices, are they (2) seeking emergency services in a hospital, and (3) is the staff not performing recall/chart audits or possibly not maximising the dental insurance?

Clinicians can and should offer to help write a narrative for the administrative team. There is a “Glossary on Dental Clinical and Administrative Terms” on the ADA’s website for help with frequent terms used in CDT coding for any team member that may be unfamiliar with them. (4) If the practice uses dental software (e.g., Dentrix), the narrative can be saved to a procedure code and reused by creating a narrative template.

Don’t neglect medical coverage

For those dental members who are insurance driven I ask, “Do you bill the patient’s medical insurance when possible?” If so many associate patients’ needs with health-care benefits, why are they not looking into all of the patient’s insurance plans? We should never begrudge a patient that does not fully understand their benefits if we are unsure of them ourselves.

Two parts of the medical pie include electronic health records (EHRs) and dental-medical cross coding.

EHRs help us directly in two ways: (1) by providing statistics for the oral-systemic link and (2) by directing access to all of the patients’ records. In addition to delivering vital health information to all providers, EHRs assist patients to participate in their own health care. (5)

For clinicians who are looking beyond the oral cavity and into the host, an EHR will provide the most recent lab work (or lack of) a patient has had. We will not have to contact the physician and wait until after the patient has left the dental chair to obtain this information. We will not have to rely on the patient’s memory of their last INR (international normalized ratio) or A1C (glycated hemoglobin) reading. Similarly, if a patient has labs drawn after experiencing tremendous bleeding in the dental chair, his or her A1C may be low. The physician who reads the lab work will be able to look at the EHR via electronic dental record (EDR) and discover the patient had a dental visit prior to the hemoglobin blood levels being drawn.

Every health-care provider being able to access a patient’s previous and existing health history is paramount to increasing patient care and safety.

Dental-medical cross coding

The benefits of dental-medical cross coding are presumably self-explanatory. Removing any possible financial burden on the patient by maximizing all their health-care coverage is one advantage. For the dental office this will increase case acceptance. Happy patients equal word-of-mouth referrals, which have been known to be the best source of new patients.

All dental entities should start learning the basics of dental-medical cross coding. Cross coding for dentistry can be initiated when patients have a medically necessary reason for a procedure or exam in the dental office, which would allow medical insurance to be billed. (6) An example is medically necessity can be periodontal procedures that are critical to surgical clearance or necessary prior to chemotherapy. (7)

Most recent versions of dental software have the capability to include medical codes, access to the medical claim form (CMS-1500), and/or comes with the medical code set preloaded in the program. If the code set is not preloaded, they can be entered manually.

There are materials for purchase, just like our CDT books and software, and classes that can be taken to provide the knowledge on what to do with the codes once you have them. There are many resources that exist to learn the medical coding structure and to keep up to date with changes. (8–11)

Conclusion

Dental hygienists are team leaders and can help the transition into primary health care. By stepping outside of the traditional box, many dental hygienists have successfully negotiated salary increases and received the respect we all deserve. We can learn the code sets and legal obligations and reap the rewards of patients being extremely grateful that we are helping them maximize all their benefits. Utilizing medical insurance when possible will decrease the amount deducted from their annual dental benefits and more patients will be able to receive the dental care they need.

I read a newsletter recently that included this powerful statement: “If you’re not helping your patients with their insurance, they’ll find a dental office that will.” (12)

EHRs and dental-medical cross coding are two valuable resources now available that will assist our profession to move beyond a single discipline. Statistics help to create a traceable, systematic delivery of patient needs that becomes recognized by all third-party payers. There is no denying the effect the mouth has on the body when periodontal clearance is necessary for chemotherapeutic treatment and dental offices begin billing medical insurance.

Here are two last sentiments:

The Centers for Medicare and Medicaid Services (CMS) has announced that “beginning February 1, 2017, CMS will begin enforcement of a requirement for prescribers, including dentists, who write prescriptions for Part D drugs to be enrolled in an approved status or validly opted out with Medicare, in order for their patients’ prescriptions to be covered under Medicare Part D.” (10) Learn what this means for your dental office so you don’t loose a large percent of patients.

Lastly, we all have voices and they can be heard. Dental hygienists have known there is a need for a gingivitis code rather than billing patients for two prophylaxes, and we have been heard. If you have a problem, solution, or anything you would like to see changed within our current CDT coding system, you the have the right to submit a request for change! There are no guarantees in life, but without taking risks, what is life? The ADA website says that “CDT change requests may be submitted at any time, and the date received determines the CDT Code version that may incorporate the requested action. The annual closing date for submissions is on the CDT Code Maintenance timeline. Any requests received after the closing date will be addressed in the next annual maintenance cycle.” (13)