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March 30, 2009 | Web Exclusive

Untangling insurance codes

In some circumstances it is possible to bill oral cancer screenings to a patient’s insurance.

by Dr. Larry Emmott


While practices using oral cancer screening systems can charge patients an additional fee to perform the tests, patients with dental insurance might not be willing to pay a fee for the screening if it is not covered by their plan.

Currently it is possible to submit an insurance claim for the tests, but whether or not the claim is paid is at the discretion of the insurance company involved. Occasionally the status of the claim will depend upon the outcome of the screening as well as any follow-up testing.

The screening code

According to Tom Limoli Jr. of Limoli & Associates (limoli.com) a leading consulting firm helping dentists deal with insurance and coding issues, “CDT Code D0431: Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures” is the insurance code that addresses enhanced oral cancer screening.

The code is placed in the diagnostic section of the CDT and is commonly used as a diagnostic code. However, notice it is specifically worded as “adjunctive and pre-diagnostic.” The code expressly precludes biopsy and cytology which are the basis for a final diagnosis.

Payer responses

Third party payers tend to take one of three options when the code is submitted:

1. There is no specific coverage for this code. This is an adjunctive procedure that is covered under an examination code such as D0150.

2. Coverage for this code is allowed only when it leads to a final treatment or diagnosis. In other words if the screening results are suspicious and a biopsy is indicated then there will be re-imbursement. If the test is used only as a screening with no follow-up, it is not covered.

3. The procedure is covered under specific contract terms.

Consultants’ position

The American Association of Dental Consultants (AADC.org) released a position paper on these procedures in March 2009 that concludes in part, “There is not at this time, sufficient evidence to provide for definitive health and economic impact through the large scale application of any of the adjunctive diagnostic aids reviewed.”

Needless to say this is not at all what the vendors who promote these oral cancer screening products believe. However, the AADC has considerable influence and this position is likely to keep insurance reimbursement minimal until further evidence of effectiveness becomes available.

Dr. Larry Emmott, an authority on dental technology, is a speaker, writer and consultant. To find out about his high-tech training programs, Technology Guides and other services, visit drlarryemmott.com or call 602-791-7071.