Insurance coding is confusing

Sept. 1, 1998
I wish to comment on Carol Tekavec`s article, "Coding exams and radiographs," in the July 1998 issue.

I wish to comment on Carol Tekavec`s article, "Coding exams and radiographs," in the July 1998 issue.

I agree with some of Ms. Tekavec`s information presented, especially the comment, "It enhances patient trust to inform the patient of the fact that one service will not be a covered benefit before the patient receives your bill."

The other point with which I agree is the statement, "Each insurance carrier will have its own policies."

I do not disagree that many companies use the time limitation guidelines that were presented; however, they are not universal and dentists should not base any appeals of denied claims on the basis of the information presented in the article. They should refer to the specific policy guidelines of the individual insurer.

More importantly, I take issue with the coding recommendations by Ms. Tekavec with respect to the "Updegrave" seven vertical-bitewing technique. There is no problem with the advice of billing CDT-2 code 00274-Bitewings-four films, since four bitewing radiographs were taken. However, it is totally inappropriate to claim that a bitewing radiograph is a periapical radiograph. The American Dental Association defines a bitewing radiograph as "interpoximal view radiograph of the coronal portion of the tooth" and a periapical radiograph as "a radiograph made by the intraoral placement of film for disclosing the apices of the teeth."

On a properly positioned and correctly exposed horizontal or vertical bitewing radiograph, one would not be able to observe the periapical area around the involved teeth, unless the teeth were anomalously short. It would be an extremely serious misrepresentation of services rendered to submit CDT-2 codes of 00220-Intraoral periapical-first film and 00230-Intraoral periapical-each additional film for the subsequent bitewing radiographs on a claim form submitted to a third party for reimbursement, as suggested by Ms. Tekavec.

The ADA recommends submission of the seven vertical bitewing radiographs as follows: billing CDT-2 codes: 00274-Bitewings-four films; 00272 Bitewings-two films, and 00270 Bitewing-single film.

The potential complication in submitting the claim coded in such a fashion is that despite the recommendation of the ADA, it has the appearance of fractionating or unbundling of a larger procedure (a seven-film series) into its components for higher compensation. The cost per film to the insurer would be greater. However, the biggest drawback is that some insurer computer- payment edits are established in a hierarchical, numerical sequence order so that the first code paid is the lowest code number in a class. In this case, the single bitewing would be paid as a benefit (assuming that there was no intervening time limitation in place from a prior submission) and the additional bitewing radiographs listed then denied, due to time limitation. Also, the total sum of radiographs could trigger another policy edit with its own attendant time limitations.

A better solution would be the submission of 00274 Bitewings-four films and coding of the subsequent three bitewing radiographs as CDT-2 procedure code 00999-unspecified diagnostic procedure, by report. The report should indicate three additional bitewing radiographs, since there currently is no procedure code in CDT-2, which adequately describes the seven-bitewing -series procedure. In this fashion, an insurer can either pay or deny benefits for the radiographs consistent with its dental policy guidelines. And, since 00999 is not a radiograph code, it will not trigger existing edits for numbers of films on the same date of service. The patient will receive the maximum benefit.

Please advise your readership that following Ms. Tekavec`s recommended practices with respect to the claims submission for seven vertical bitewings could have the potential result of having a third-party insurer report such billing practices to the state board of registration in dentistry for inappropriate and misrepresented claims submission. In some circumstances, a report could be sent to the state attorney general`s office for insurance fraud.

Allyn E. Segelman, DMD, SM

Dental Director,

Blue Cross and Blue Shield of Massachusetts

The author replies: Dr. Segelman`s comments on bitewing radiograph codes illustrate well the problem that the average dentist has when attempting to report procedures for which there currently are no completely accurate codes. According to Dr. Segelman, neither the method mentioned in my July 1998 column, nor the alternate format recommended by the ADA is correct and could be considered fraudulent.

It has never been my intention to recommend any coding procedure that is not completely truthful, ethical, moral, and accurate, as I know it would never be the intention of the ADA. As an alternative coding format, I appreciate Dr. Segelman`s comments and his recommendation of using the "unspecified diagnostic procedure, by report" code. The "unspecified" codes always can be used, although patient reimbursement often is delayed due to the need to have additional insurance consultant review.

All of us are looking forward to a solution to this and many other similar coding dilemmas in the CDT-3 in the year 2000.

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