Reimbursement for radiographs

The new ADA CDT-2005 codes have been in effect since January. All dentists and payers must use the most current version of the ADA codes as per HIPAA regulations.

The new ADA CDT-2005 codes have been in effect since January. All dentists and payers must use the most current version of the ADA codes as per HIPAA regulations. Major changes, including 39 new codes, 47 revisions, and three deletions have occurred. Using the wrong codes can result in payment delays.

Radiographs, insurance, and utilization review

The ADA general description for “radiographs” includes the stipulation, “should be taken only for clinical reasons as determined by the patient’s dentist.” Increased utilization review by insurance carriers has put a spotlight on the “clinical reasons” and frequency rate of radiographs. Documentation of the reasons radiographs are taken is now essential before many plans will pay radiographic benefits. Previously, four bitewings were benefited automatically once or twice a year by the majority of carriers. Now, many plans require evidence to justify the need for bitewings or other radiographs for payment to apply. (Keep in mind that any number of radiographs may be taken according to the clinical opinion of a dentist. Any restriction imposed by insurance carriers is only based on their eligibility for payment.)

“A Guideline for Prescribing Dental Radiographs” diagram - published with the cooperation of the FDA, AGD, AAP, the ADA, and others - details prevailing concepts concerning patient “categories” and the intervals for radiographic exposures. Some of these guidelines may be surprising to dentists and their staffs. For example, adult “recall patients” with existing clinical caries or who are at high risk for caries, are appropriate candidates for “posterior bitewing examination at 12-to-18-month intervals,” not automatically every six months.

Recall patients with no clinical caries and who are not at high risk for caries are recommended for “posterior bitewing examination at 24-to-36-month intervals.” That is quite a long time period! Because of this, you need to anticipate the need for explanations and include a brief narrative - hand-written or computer-generated - directly on the claim form. For example, you might note, “Suspected interproximal decay maxillary right and mandibular left.” The patient’s chart also should contain this information. What the radiographs subsequently revealed should also be noted on the claim form and in the chart. For example, you might note, “Interproximal decay discovered on #3 and #19.”

Radiographic exposure - even when the reason for the radiograph is documented, with no subsequent revealed pathology or “suspicious lesions” - may not be paid. Even worse, you may be initially paid for the radiographs, and then later, the insurance company may demand you return the payment. If a patient had documented reasons for bitewings in 2005 and then again in 2006, but no decay or other problem is revealed at either time, the carrier may not automatically pay for the bitewings in 2006. Or, the insurer may initially pay for the 2006 bitewings, then later request a refund from you! Your chart and progress notes are your only defenses. Be sure you are documenting your patient’s specific problems, your request (as the doctor) for radiographs, and what was revealed by those radiographs.

Payment for D0210-Intraoral, Complete Series

A complete series is typically considered by dentists to be seven to 14 periapical radiographs, including the necessary two to four bitewings. Many insurance carriers regard any combination of radiographs taken on the same date - which meets or exceeds their allowable payment for a D0210-Complete Series - to be “equal” to a D0210. Many carriers also consider a D0210 and a D0330-Panoramic Film to be “equal.” This can be a problem when future radiographs are required. Some carriers only allow a benefit for a D0210 once every three to five years. Future “Complete Series” radiographs may be denied.

Insurance restrictions on the benefit for radiographs vary so much that it is difficult for a dental office to anticipate the level of reimbursement available to a given patient. It usually is best to let patients know in advance that the radiographs being taken are necessary for a proper diagnosis, but their insurance may or may not cover the cost. Because patients typically believe preventive and diagnostic procedures are always covered at “100 percent,” problems arise when they are surprised after the fact by the limited nature of their insurance.

Carol Tekavec, CDA, RDH, is the author of the Dental Insurance Coding Handbook Update CDT-2005. She is the designer of a dental chart and is a lecturer with the ADA Seminar Series. Contact her by phone at (800) 548-2164 or visit her Web site at www.steppingstonestosuccess.com for more details about the new code handbook and her patient brochure, “My Insurance Covers This ... Right?”

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