3 Facebook Misinformation Antidotes
Social media has become the primary means means for businesses, politicians and decision makers to reach their audiences, people are casting newspapers and traditional media aside, instead keeping themselves updated via social networks such as Facebook, Twitter and more. This is no less true for dental coding questions. Daily questions are asked on numerous Facebook groups with a resulting responses that from the ridiculous to downright fraud. The team at DentalCodeology have decided, you need a place to get accurate information.
- FB Post: My question is can you use D4346 interchangeably with D1110? We have a large population base already coming for additional cleanings due to gingivitis. Are we allowed to bill out two D1110 and one or two D4346 in a year? Also in your experience have you noticed if insurance is covering the D4346 at all?
DentalCodeology FB Misinformation Antidote: As far as billing, your codes should reflect the treatment provided based on the diagnosis. There isn’t a ‘sequence’ per se. If one time they have < 30% inflammation in the absence of periodontitis then they qualify for D1110. If they then present with >30% inflammation in the absence of periodontitis and your records reflect this then they qualify for D4346. That is the simple response. Your coverage question is more difficult because of 2 factors. One is when there is a newer code, though the D4346 is 2 years old, policies don’t often catch up for a year or two. The 2nd reason is policies are so very different. I have definitely heard it reported by many that when they document properly, there is coverage under D4346. Sometimes the same as D1110. Which brings me to my final point and that is coding, as I mentioned, must be based on the condition diagnosed and treatment selected. And the office must use the code that most accurately describes that treatment. To choose codes based on payment by using a greater or lesser code is called remapping-most of us know it as down-coding. We have seen 3rd party carriers do this so we think it is okay. A carrier can and a practice can’t. Why? When a carrier changes the code, it is based on a contract and $$. When a practice does, it can be considered fraud because we are saying we did something different than we actually performed. Many of us understand the problem with up coding which is charging for a higher level than performed. We sometimes don’t realize it is just as problematic when we down-code. Using D1110 instead of D4346 is exactly that. As far as any office being late to the party of change, it is my experience that often it takes 5-10 years for things to really change in dentistry.
- FB Post: Why can’t we change a code, the carriers do?
DentalCodeology FB Misinformation Antidote: There is a type of cost containment measure used by many 3rd party payers called the least expensive alternative treatment abbreviated as LEAT. If this clause in a 3rd party agreement, when there are multiple viable options of treatment available for a specific condition, the plan will only pay for the least expensive treatment alternative. This has traditionally been called under-coding. Or the other end of the spectrum, over-coding which is the intention use of a higher payment code. The confusion arises because it seems to acceptable for a 3rd party carrier to change codes but it is not acceptable for a practice to do so. The term used by 3rd party carriers is remapping. Under LEAT clause, they can change the code. A dental practitioner cannot, and it could be fraud because the documentation is not accurate, it reflects care different than what was rendered.
- FB Post: Our patients are complaining about fees because their insurance is coming back with the low coverage. They say the carrier said our fees are above what is reasonable and customary.
DentalCodeology FB Misinformation Antidote: A place of confusion exists for both patients and clinicians with the terms reasonable and customary or usual and customary (UCR) fees.UCR is determined by carriers, NOT by the practice. Any limits are the result of a contract between a plan purchaser and the 3rd party payer. Dental professionals know this yet can forget and can end up sounding defensive when patients ask. An insurance company has fee information and makes determination by zip code. Dental benefit carriers can misinform practices when they state the ADA provides UCR per zip code. The ADA does not provide fees of any kind in any way. As noted, ADA can provide a survey of fees charged. This is not the same as setting fees.This is an insurance carrier determination that has little to do with the cost of doing business in a particular practice.
UCR is often constructed this way:
- Usual means a fee an individual dental practitioner frequently charges for a specific procedure as measured by a dental plan often based on zip codes
- Customary means fee decided the administrator of a dental plan that establishes a maximum benefit
- Reasonable means a fee charged for a specific procedure that has been modified by complications as decided by a dental plan