Make Sure Coding Matches Lab Cases and Fees

Without realizing it, a simple disconnect can occur between lab cases and fees/codes which are ordered/billed to a patient and the codes used to prepare the associated insurance claim.  When there are discrepancies in coding, it can open an office to audit challenges as well as profitability concerns.  It is important that doctors and team members make sure that coding used for insurance claims matches what is being sent, received and billed by the lab.   Here are some common mis-coding scenarios where you’ll want to always “double-check:”

Crown Materials

There are a number of different codes for crowns and bridges based on the material used.  A “change in plan” can result in the most common type of coding error when the type of material “planned” for treatment may not always be the material used due to what is determined best during the treatment process itself.  It is useful to confirm the material actually used after treatment, and ensure the correct code is used on the claim form when finishing the prep appointment and lab script.

Dentures 

This is typically the largest financial mistake which can occur, as dentists aren’t always aware of how labs bill for services.  For a couple of examples:

Flipper – Flippers on average involve 1-2 teeth from the lab’s point of view and pricing. When more teeth are required, they will usually charge a higher fee.  Therefore, when ordering a flipper or acrylic denture from the lab, make sure your claim coding and pricing matches.  A flipper of say 1-4 teeth may be an interim partial denture (D5820/D5821) while more than 4 teeth may be more accurately a resin based partial denture (D5211/D5212) with a higher fee.

Adding Teeth to Partials – When the lab adds a tooth to a partial denture, sometimes they can just add acrylic and the tooth, which results in a lower lab bill.  However, often the lab will need to add to the metal framework, which requires laser welding, resulting in a much higher cost.  If they must add to the frame, that now becomes a partial denture repair (D5621/D5622) in addition to the D5650 – adding a tooth.  The combination of codes helps bring the fee up high enough to pay for the added lab fee.  What was initially ordered must “change course” during the lab process, impacting the fee charged and claim coding required.

Keep in mind that insurance will only reimburse for one denture code.  Know this when estimating for patients.

Alternatively, one could just instruct the lab never to add metal, and therefore keep your costs down.  If the unsupported resin breaks around the new tooth, creating a new partial denture would be the next step.

Implant Screw-Retained Crowns  

The most common misconception around coding even with experts is how to code a screw retained crown.  This stems from the description in the ADA coding companion, which incorrectly claims a screw retained crown is an implant retained restoration.

The problem here is that the ADA codes are supposed to only report what was done, NOT to define what clinical procedures dentists do and do not perform.  The misunderstanding is a screw retained implant crown has an abutment inside, and the lab will be charging the office for that abutment.  Since the office is charged an abutment by the lab, the ONLY way to code is by coding an abutment, to do otherwise would be fraud.  Always report what was done is the golden rule with coding.  Coding does not change between a screw retained or cement retained crown, as both require an abutment.  Therefore, always use an abutment-supported restoration (D6058-D6064) for either situation along with an abutment code (D6056/D6057). 

An implant retained restoration (D6065-D6067 and D6082-D6088) is one where the implant and abutment are a single fused piece of metal, which are often termed as miniature implants with no screw access.  

Any type of screw access in an implant means an abutment must be placed into that access, and therefore an abutment must be coded to follow the golden rule (D6056/D6057).

The financial impact is that an implant retained crown code is far less expensive than an abutment + abutment retained restoration.  This only makes sense if the implant has a location to cement a crown directly to the implant, which is the only time the lab would not be charging the dentist for the abutment connector.  

Overall

As you can see, there are multiple ways in which incorrect coding could cause challenges both with audits and with financial implications for the office.  Making sure you correctly match the “actual” service after treatment with the claim code(s) selected will help keep you safer as well as more financially stable.