Sarah Beth Herman
Top 7 Hygiene Dental Insurance Billing Questions Answered
Your Dental Hygiene Billing Questions Answered
1. Why are dental insurance companies allowed to change the dental codes we submit to them?
I think this question might be talking about third-party payer remapping (down-coding) of dental claim submissions. The interesting thing here ... dental insurance policies actually determine if codes can be changed, not the dentist or provider. Crazy, huh?
So, yep, you guessed it, carriers can change a submitted code, but professionals cannot. Codes changed by a carrier are always based on the contract and money. When a professional or practice, under the professional license, changes a code for the purpose of increasing payment, it is fraud because the practice is saying it did something different than the actual treatment.
2. D4910 +/- D1110 Can we alternate these codes?
Here is the skinny on this...brace yourself if your office is submitting this way....well...
When an office deliberately alternates the D1110 and D4910 to maximize insurance benefits it is considered fraud. We must code for the procedure being performed. By doing otherwise, the attorney general could make a convincing case for the prosecution of an office. While codes can be changed regarding policy treatment should be based on clinical diagnosis, not on policy or coverage of benefits.
3. Help me understand the D4346 code...Can we bill this in addition to the D1110 or is it a stand-alone?
The D4346 code addresses the procedure between a prophylaxis and a scaling and root planing, it is a separate procedure and not an add-on.
• Localized inflammation <30% teeth = D1110/D1120
• Generalized inflammation >30% teeth = D4346
• Periodontitis = D4342/D4341
4. Can you help me with a D4355?
This is a preliminary superficial removal of plaque and calculus. A D4355 is for cases where deposits are so heavy that they interfere with the ability to do a comprehensive oral evaluation. A second visit would be scheduled for an exam and diagnosis, followed by the appropriate hygiene visit(s) for definitive treatment (prophy, scaling in the presence of moderate to severe inflammation, scaling and root planing).
5. How do I explain coverage to a patient?
Coverage is a contract between a third-party carrier and—most often—a patient’s, spouse’s, or parent’s employer. Some dental offices have contracts with dental benefits carriers (insurance companies). All of these are also contract negotiations. Coverage or non-coverage is based on the agreements negotiated with each of those. The dental office is merely a facilitator of filing claims and the contracts and verbiage therein determine payment. No matter how much we try, we can not ever guarantee payment.
6. How do we decide what we charge for services? A practice can choose what fees to charge. Practice fees should be based on the cost of doing business plus a reasonable profit. Often times, people think they should pull a report of the common UCR in the area. The truth is, to determine the actual Cost of Goods Sold (cogs) or Cost of Services Sold and multiply that by 3. For example, if you pay your hygienist $40 per hour and the supplies, rent and utilities cost $15 for a 1-hour cleaning appointment your math may look something like this:
$40 + $15 = $55 $55 is the COS COS x 3 = $165 fee
If the cost is too high for your area, then we must modify the time spent on the service, the cost of supplies, increase services rendered to generate more revenue or modify the cost of the staff (payroll).
7. What should I verify when asking for eligibility? Here at Dentistry Support, we verify all insurance for all aspects of dentistry. Here is a snippet of the preventive section of our customized Break down of Benefits form. This section is fully customized for your dental practice.
For more information, feel free to email me directly at firstname.lastname@example.org
Happy to help,