We often operate our practices on autopilot, relying on knowledge passed down from administrators, clinicians, and mentors. However, this information can be flawed, leading to billing practices based on outdated or incorrect protocols.
Estela Vargas, CRDH.
Due to a lack of awareness regarding any alternative perspective, we assume that our actions are ethical and practical. However, this mistake can lead us down a dangerous path that can cost us thousands of dollars or, worse, negative actions taken against our licenses or lawsuits or even prison time.
Let’s explore a real-life scenario where an incorrect billing practice can lead to a practice being audited.
A biller reached out on the Remote Dental Billing Connections group on Facebook for help drafting a narrative for a large dental insurance claim. The claim totaled $4,800.
The doctor was upset that the explanation of benefits (EOB) showed a disallowed charge and a write-off. The doctor felt it was unjust for insurance to dictate treatment and what they could and couldn’t charge the patient. The procedures billed were as follows, in no specific order:
- A single bitewing image
- A porcelain crown
- A prefabricated post and core
- A gingivectomy to allow access for a restoration
- Crown lengthening
The insurance company covered the cost of the bitewing, post and core, and crown. However, they denied coverage for the gingivectomy and crown lengthening. The denial reason stated that tissue preparation is included in the restoration service and therefore cannot be billed separately. It disallowed the charge for both periodontal procedures.
The term "disallow" carries heavy weight in the dental industry. It essentially accuses the dentist of performing a procedure that was not medically necessary. As a result, the dentist cannot charge the patient and must absorb the cost.
My first response to this type of statement on an EOB is outrage. An insurance company cannot dictate what is medically necessary and what is not. They can process claims according to the policy and coverage guidelines.
How did this doctor get here, and what can be done to combat disallows and prevent the doctor from being flagged and audited? Let’s examine what each procedure involves before we dive into how to fix it.
- Crown lengthening: This surgical procedure involves the removal of both bone and gum tissue surrounding a single tooth. The primary goal is to expose more of the tooth structure, facilitating crown placement and ensuring a healthy periodontal apparatus (healthy bone and gums). This procedure is often necessary to create or restore biologic width and preserve the long-term prognosis of a natural tooth.
- Gingivectomy to access restoration: This procedure removes excess gum tissue to allow access to prepare and restore the tooth to function when decay or a fracture is below the gum line.
In many cases, a gingivectomy is integral to the crown lengthening process. By removing gum and bone tissue, the dentist gains better access to the underlying decay or fracture and can reshape the gum line to achieve optimal results for crown placement.
Therefore, it is generally considered inappropriate to bill for a gingivectomy to allow access for a restoration (D4212) separately when performed as part of a crown lengthening procedure when the tooth is prepped, the core and post are completed, and the crown is cemented all in the same day.
To avoid billing issues and potential audits, dental practices must maintain thorough and accurate documentation. When crown lengthening is performed, the clinical notes should clearly outline the following:
- Periodontal charting: Detailed measurements of the probing depths, recession, attached gingiva, and furcation involvement, if any
- Pre and postoperative x-rays or images: Visual evidence demonstrating the removal of hard tissue (bone) and the resulting changes in tooth structure and gum line
- Stable periodontal foundation: Documentation confirming that the surrounding gum and bone tissues are healthy and conducive to long-term tooth health and stability
Corrective action is necessary if a gingivectomy has been billed incorrectly alongside crown lengthening. This action typically involves submitting a corrected claim with supporting documentation that justifies the crown lengthening procedure and requests the removal of the gingivectomy charge from the patient's billing history.
Unbundling procedures -- intentional or unintentional -- can have severe consequences for dental practices. These may include:
- Audits: Billing codes that include each other will be flagged by insurance companies or government agencies.
- Penalties: Financial repercussions include fines and repayment of overbilled amounts.
- Loss of reputation: Harm can result in the practice's reputation with patients and the subsequent negative talk in the local community.
- Legal action: In extreme cases, unbundling can lead to criminal charges and potential imprisonment.
Accurate and ethical billing practices are fundamental to the integrity of any dental practice. By understanding the relationship between procedures and how they translate to codes, maintaining meticulous documentation, and promptly correcting billing errors, dentists can protect themselves from the risks associated with unbundling and ensure compliance with coding and billing standards.
Estela Vargas, CRDH, is the founder and CEO of Remote Sourcing, a dental insurance billing and revenue recovery service. She is a graduate of Miami Dade College's dental hygiene program. Vargas' extensive background in the clinical arena of dentistry is coupled with her experience as a practice administrator and business executive.
The comments and observations expressed herein do not necessarily reflect the opinions of DrBicuspid.com, nor should they be construed as an endorsement or admonishment of any particular idea, vendor, or organization.
