Its all-inclusive!

Insurance carriers frequently utilize a simple method for reducing their liability. It is the "all-inclusive" clause. Rather than address the components of treatment procedure by procedure - with a designated fee or percentage per code - many carriers group procedures together under one "all-inclusive" heading. Combining procedures typically results in a reduced benefit for the patient and a smaller payout for the carrier.

Carol Tekavec, RDH

Insurance carriers frequently utilize a simple method for reducing their liability. It is the "all-inclusive" clause. Rather than address the components of treatment procedure by procedure - with a designated fee or percentage per code - many carriers group procedures together under one "all-inclusive" heading. Combining procedures typically results in a reduced benefit for the patient and a smaller payout for the carrier.

For example, many insurance carriers only allow an "all-inclusive" benefit for a quadrant of osseous surgery [Code D4260-Osseous Surgery (Including Flap Entry and Closure)] and any other procedure, despite the fact that the other procedures may be completely separate. If a bone-replacement graft (Codes D4263 and D4264), guided-tissue regeneration (Codes D4266) or D4267), extractions (D7110 and D7120), or any other procedure is performed at the same time as a D4260 service, the carrier only may consider the D4260 for benefit payment. The patient must pay the balance.

Other examples of "all-inclusive" bundling include radiographs, where seven periapicals are considered a D0210-Intraoral Complete Series; and amalgam and composite restorations, where any adhesives, liners, and bases that are required are not payable as separate services.

Provisional restorations or replacements also are considered "all-inclusive" by many carriers under the code representing the final restoration or replacement. For example, a D2799-Provisional Crown is placed as an interim restoration to allow adequate time for healing or completion of other dental procedures. When a provisional crown is necessary, its cost is considered to be included under the code for the subsequent and eventual final crown. (However, Code D2799 is not appropriate for the temporary crown that is placed for a patient before the final crown is returned from the lab.) If any insurance payment is initially allowed for a D2799-Provisional Crown, the amount paid toward it is typically subtracted from the payment for the final restoration when it is placed.

Sedative fillings (Code D2940) are temporary restorations used to relieve pain during an interim period. They also are frequently considered "all-inclusive" by insurance carriers. Code D2940 often is billed, but seldom is paid when used in conjunction with D3110-Pulp Cap-Direct, D3120-Pulp Cap-Indirect, D3220-Therapeutic Pulpotomy, and the new D3221-Gross Pulpal Debridement. Insurance carriers monitor utilization of D2940. The few that provide coverage normally will not pay for any portion of the cost unless 30-60 days pass between placement of the D2940 Sedative Filling and placement of the final restoration. Some carriers cover the code once per tooth every five years or once per tooth per lifetime. Many insurers will not cover the procedure separately under any circumstance, but consider it to be "all-inclusive" under the final treatment code.

As mentioned above, while D3110-Pulp Cap-Direct and D3120-Pulp Cap-Indirect frequently are billed separately by dentists, they are infrequently paid separately by insurance carriers. They also are considered to be part of a larger service and, therefore, "all-inclusive" under the code for whatever final restoration is placed. Only a few carriers may cover a D3110 service if it is performed on a different day than a final restoration. (A time period of 30-90 days usually is required between the D3110 and the final restoration for a payment to apply. )

The new code, D3221-Gross Pulpal Debridement, is designed to address the problems that surround reporting a "gross pulpal debridement" or "open and drain" for a patient who presents with pain on an emergency basis. This patient may or may not eventually complete endodontic therapy, either with the treating dentist or by referral to a specialist. If a specialist completes the endo, a payment likely will apply to the original general dentist for this code. If the original dentist ends up completing treatment, the insurance carrier will likely consider the procedure as "all-inclusive" and will reduce the benefit for a completed root canal by the amount already paid for the D3221.

Treatment alternatives, costs, and potential complications should be discussed in a detailed conference with the patient before treatment begins.

Carol Tekavec, RDH, is the author of a new insurance-coding manual, co-designer of a dental chart, and a national lecturer with the ADA Seminar Series. Contact her at (800) 548-2164 or visit her Web site at www.steppingstonetosuccess.com.

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