What you need to know, what you can ignore and how to keep from getting into trouble.
For those who still write paper checks, the New Year can be a tricky time. It can take several attempts before writing “2018” replaces the habit of writing “2017.”
And the New Year poses similar challenges for the dental practice’s insurance coders. When the calendar ticked over to Jan. 1, 2018, the insurance codes from 2017 changed. While most are, of course, the same, others have been removed, some have been revised, and still others are brand-new.
The American Dental Association’s Code Maintenance Committee decides on changes to the formal list of codes. For 2018, there are 18 new codes, 16 revised codes and three deleted codes. The Code on Dental Procedures and Nomenclature (CDT) 2018 adjustments mean fewer claims rejections and speedier reimbursement.
“There are some really exciting changes that are coming up in 2018,” says Patti DiGangi, RDH, a coding consultant. “Codes are updated once a year, and what the updates give us is an opportunity for new and innovative ideas, products and procedures.”
Maybe the most compelling new code is D0411, which covers in-office, point-of-service HbA1c testing, a blood sugar measurement that can be an indicator for diabetes.
“This is going to be huge,” says Katrina Sanders, RDH, a clinician and practice consultant, and member of the Modern Hygienist editorial board.
“It’s the first time that we’re going to be able to do a blood draw in the office and be able to bill for it using a dental code.”
Previously, blood sugar testing was covered when taking a simple blood sugar reading. Now, however, more comprehensive results are billable.
“In office, if we did do a blood draw, we just took a blood sugar reading that moment and an HbA1c gives you a survey over time,” Sanders says. “Blood sugar is just going to tell you if your diabetic patient has a low blood sugar at that moment. Maybe they had just taken their insulin and hadn’t eaten breakfast, so it just gives you a reading of, ‘Are you a risk in our office right now?’ This is the first time we are doing an HbA1c, which allows us to find a marker for patients that maybe are uncontrolled diabetics, but also for patients that have diabetes and may not know that they have it.”
This code makes it possible for the clinician to be more involved in the patient’s overall health.
“It’s not a diagnostic test; it’s a screening test,” DiGangi observes. “But with the epidemic of diabetes in our country, it gives dentistry an opportunity to help guide our patients and work more closely with their physicians, or even get someone to a physician who may not even know they have a problem with their blood sugar and possibly have diabetes.
“What’s important about that code is not so much that it’s a code that’s going to make us into physicians, but it’s going to connect the oral systemic,” she continues. “We keep talking about it, but this is a really definitive way to take action. It gives them tangible reasons to follow up with their physicians.”
Insurance professional and consultant Teresa Duncan, MS, warns, however, that HbA1c testing should be performed conscientiously.
“I always caution that just because there’s a code doesn’t mean you should bill it,” she advises. “You should only bill it if it’s actually being done in your office and if you’re prepared to handle the consequences of that. What I mean by that is that when you give someone a diagnosis or let them know their levels are off, that’s a serious conversation you’re about to have with that patient. Diabetes is a life-changing diagnosis.
It’s not just a very low-effort test. We’ll need to pay attention to what and how we’re telling patients that their health status has changed.”
Up next: Teledentistry
For some patients, getting to the doctor’s office can be difficult - if not impossible - and one effort to reach those patients is through teledentistry. Hygienists could be in an affiliated practice or they may own their own practice, in states where that’s permitted. It could also apply to dental therapists.
“There are already some services that provide teledentistry reimbursements. Some states do,” Duncan says. “California has been providing this in certain state programs, but the fact is that we don’t have enough providers in certain areas. Teledentistry is a good way to offset that by having the ability to check in with a doctor that is not necessarily on-site. We can still help patients that can’t get to a doctor’s office. Maybe they’re not mobile or they live very far away. Maybe they just cannot afford to take time off of work. There are many different uses for teledentistry in these situations. I feel like we are following the trend set by medical plans. Medicine has had these types of codes for a long time.”
“It’s been key to getting hygienists out to rural areas and to be able to perform services,” Sanders observes. “But, legally, they still need a dentist’s eyeballs on the patient’s case. So, they do teledentistry, which allows them to take X-rays and intraoral photographs and send these images to a dentist. They’ve got a contract with that dentist who will open up those files, they’ll take a look and if they see anything suspicious, they will be available for a consult. The problem has been that there’s no code to allow for payment of the doctor who is reviewing the radiographs or the intraoral photos.”
In the past, hygienists may have just paid a stipend to a dentist for their services.
“Now, there will be a recognized code by the CDT, and the hope is that now insurance companies will be able to reimburse that stipend so that doctors are getting paid, kind of like an exam,” Sanders says.
Two new codes cover teledentistry: D9995 for synchronous communication and D9996 for asynchronous communication. The difference between synchronous and asynchronous is whether the communication is performed in real-time or the information is saved and forwarded to the dentist for later review.
“Synchronous means a direct connection like FaceTime,” DiGangi explains. “Asynchronous is like an email because you write it at one time and it is read and interpreted later.”
Those teledentistry communications extend beyond a patient visit and can include other members of the dental team, too.
“A lot of times people think of teledentistry as being able to access more care in public health, and, yes, it is, but in addition, it’s a way for us to better connect between dental professionals,” DiGangi says. “We’ve long been saying, ‘Here’s your little referral card,’ and we send people over to a periodontist and the periodontist sends a little card back. Well, we can actually do better patient sharing and better patient connections with the use of teledentistry.”
Evidence of teledentistry’s effectiveness was key for the creation of the new codes.
“The code committee looks at these things and votes on these things based on a whole bunch of different reasons,” DiGangi says. “What the people that submitted for the teledentistry code have done on this - what they can show - is that care in a teledentistry setting is equal to what you can do in a brick-and-mortar office. What teledentistry can do is be a way of expanding a practice without having to build another treatment room. Because you can send a hygienist or an assistant out to a senior center, they can do a screening on the 50 seniors that live there, and if they find there’s something going on or if the dentist sees and diagnoses, either synchronously or asynchronously, that 10 of these 50 need some kind of dental care, those 10 dental patients now go to that dental office.
“So, yes, it is a bit of a forward-thinking thing. I wouldn’t say the codes committee are the forward-thinking people, but when they were presented with teledentistry codes a couple of years ago, they said no, and after they said no the first time, the ADA House of Delegates looked into this and they actually created policy on the use of teledentistry. So, when the codes came back to the committee, the ADA - in a proactive way of looking at the future of dentistry - decided that these codes were appropriate.”
Teledentistry has the potential to create big changes in dentistry, especially if it is used in conjunction with other healthcare disciplines.
“Teledentistry is something that is relatively new, but it’s going to take dentistry, I think, into an entirely different realm with the opportunities that we can have to collaborate with other practitioners, collaborate with other medical providers,” DiGangi says. “For instance, let’s take the HBa1c plus teledentistry and now we really have a different kind of connection and way of thinking about what we can do as dental professionals.”
Up next: Interim caries arresting medicament application
Interim caries arresting medicament application
A revised code expected to be important affects D1354, interim caries arresting medicament application. The revision puts a finer point on the code that was first introduced in 2017.
“Codes are not product-specific,” DiGangi explains. “At this point in time, one of the products that fits under that is Silver Diamine Fluoride. It’s a product that was approved in 2014 by the FDA. It’s a caries-arresting medicament, which is different than other types of fluoride. One of the things about that code that changed is that it was through the American Academy of Pediatric Dentistry. It was used a lot in the pediatric world, and they said it needs to be a per-tooth procedure. This is where codes can really make a difference in influencing how we practice.”
“This is the Silver Diamine Fluoride that they’re talking about,” Sanders adds. “It was a code that allowed us to put in cavity liners and glass ionomers, but this is being very specific to clarify the nature and scope on what kind of medicaments they’re using. And in this example, they don’t necessarily say Silver Diamine Fluoride. This proposal was brought to the code maintenance committee by the American Academy of Pediatric Dentistry with the intention of, essentially, allowing Silver Diamine Fluoride to have its own, unique, special code.”
And while codes are not product-specific, the efficacy of Silver Diamine Fluoride led to D1354’s fine-tuning.
“The Silver Diamine Fluoride really has boomed quite a bit, I would say just in the last year-and-a-half, just because the research is so definitive on how we can help arrest decay in patients that require additional management,” Sanders says. “It’s not fun to numb up a young child, to try and get their decay to stop. So, we can just put a little liquid right on their tooth and it just stops the decay. With that trend of Silver Diamine Fluoride, it’s kind of booming in the industry. There’s been a need for that.”
Getting ready for the new year
While coders need to be aware of what is new in coding, there are also some best practices that improve the overall process of dental coding.
“Bill out for the procedures that your provider did,” Sanders advises. “A lot of offices, internally, down code before they bill out. A great example is, let’s say a patient has an insurance benefit where they are a perio maintenance patient, and let’s say their benefits allow for two perio maintenances and two prophys in a calendar year. So, essentially, they’re going to get paid for two 4910s and two 1110s, and what the office will do is alternate back-and-forth - they’ll bill a 4910 and in three months a 1110, and then they’ll bill a 4910 and then a 1110. And that is really not the appropriate way to do it.
"What they should be doing is billing out the actual service that was performed," she continues. "They should bill a 4910 and then in that narrative they can include something to the effect of, ‘Please down code as necessary,’ and that permits the insurance company to be the ones to down code and say, ‘Okay, you’ve already had two 4910s for the year, so I’m only going to pay you for these as a 1110.’ As a hygienist, that’s probably the most frustrating thing because what’s happening is we have license numbers, and it may look like we’re being negligent providers because we’re doing a prophylaxis on a periodontally involved patient. That is negligent - it’s unethical - and that’s not the procedure that was performed.”
Staying on top of software updates is always recommended, but especially at the start of the new year.
“At the end of the year, pay attention to any information your software sends out,” Duncan says. “You may even want to make a point of visiting their page and seeing if there have been any updates for the end of the year, and there almost always is. Software companies will push a patch through with the new codes going into effect Jan. 1, 2018. The last thing you do at the end of the year is run that update so you have the new codes for the new year.”
It seems like something that should go without saying, but there are practices that do not update their software as recommended.
“Computers should be updated, but offices still are not always updating their software, they’re not always updating their codes, so it’s really an interesting arena we’re working in because the majority of practices are cottage industries - they can do whatever they want within the walls of their practice, and that’s a challenge we have,” DiGangi says.
The end of the year is a good time to compile carrier reports, too. While the reports can be generated any time, a year’s end compilation allows the practice to start the year with meaningful numbers.
“We learn how much production was generated by each carrier so that we have a baseline as to how much revenue is generated from each insurance company,” Duncan says. “This is more of a historical report. And, of course, you could generate it at any time, but make sure you have a record of that information because in the coming year you may have to make a decision on participation in those networks. Ideally, you would make such decisions based on information like revenue amounts and patient counts.”
Rather than simply reporting the procedure, DiGangi recommends coding patients’ diagnoses – especially as health records become more interdisciplinary.
“That’s not something that we’ve done routinely in dentistry because codes have been procedure codes,” DiGangi says. “Now we’re moving very quickly toward diagnosis codes. The benefit form already has a space for diagnosis codes. Some more leading-edge offices are already using the diagnosis codes. Diagnosis codes are not something that we are used to at all in dentistry, but it is going to be required because we are moving toward interoperable electronic health records. What that means is that dentistry connects to medicine that connects to pharmacy. In order to do that, dentistry needs to be using diagnostic codes because the treatment of patients is not just about the treatment, it’s about, ‘What’s the diagnosis?’”
Up next: Paying attention to detail
Attention to detail
There are a lot of specifics involved in dental coding, and paying attention to detail will help the practice, the patients and the overall coding system. First, pay attention to patients’ specific insurance plans.
“We still fall back in the habit of treating an insurance policy versus treating a patient,” DiGangi observes. “The problem is we often don’t even know what that insurance policy reads.”
She uses an example from her lectures where she asks attendants what type of car insurance they have.
“One will tell me State Farm, another will tell me GEICO and the third will tell me someone else,” she says. “So that means, if we get in a car accident, that we have coverage over certain things, and they automatically say, ‘No, we don’t because we have different policies.’ Well, that’s just as true as in dental. What happens is we treat policies because we think, ‘Well, Delta doesn’t cover that.’ That could be very wrong. Our job is not to treat an insurance policy; our job is to treat the patient and code it accurately. If there is coverage under their insurance policy, wonderful.”
Utilizing the proper codes helps ensure that the system provides what it needs.
“We only use a limited number of codes, rather than using all of them that are available, based on what we think the insurance is going to pay,” DiGangi says. “An example would be oral hygiene instructions. Teaching somebody how to take care of their mouth is pretty important, probably the most important prevention thing we can do, but that’s probably one of the least used codes: D1330. And how we code affects what codes we get; it affects the coverage for codes. Our behavior makes a difference to the system.”
“When these codes are created by the CDT, we need to be using them as providers,” Sanders adds. “We need to be billing them out to show that we are using these codes, otherwise they’re going to go through review and they may begin to start throwing some of these codes out that are heavily unused. There are a lot of insurance companies that do reimburse for some kind of oral cancer screening therapy like OralID, VELscope or ViziLite one time a year. And I think that gets missed a lot. We’re not performing risk assessments on our patients in office. We are not evaluating their risk for HPV, their tobacco habits, their alcohol intake habits, things like that.”
Paying attention to what’s going on should also extend beyond the practice’s walls.
“I don’t think there is enough obsessing over what goes on outside of the office,” Duncan says. “I think we obsess way too much over what’s going on inside our office and we don’t see things like network changes coming at us. That can really throw our office for a loop when, all of a sudden, their fee schedules are dropped and they have no idea why. I think diligence is really, really smart. A lot of people, though, never look outside their offices to see what’s going on. So, to me, it’s more of, ‘Hey, what are the other offices down the street experiencing? What are the new networks coming into your area? What are the new employers coming into your area and what plan do they have?’ and then, ‘What are the companies that are going out of business?’ And they’re leaving and all of a sudden those patients don’t have insurance. So, to me, it’s more of what they don’t look at outside of the office than what is inside the office.”
Like every year, coding and insurance changes can be a nuisance and a headache, but if they are tackled head-on, they can be less of a chore and more of an opportunity to benefit the practice, the patients and, ultimately, the coding system, itself.