With ever-changing dental billing guidelines and coding updates, staying on top of your practice’s billing management can feel impossible. However, with the right information and resources, dental billing and coding is a lot simpler than you’d believe. In this guide, we’ll cover dental billing basics, up-to-date coding information, and resources that’ll make your billing a lot easier.
Dental Billing Codes and Guidelines
Dental CDT Codes
Let’s dive right into what many providers consider to be the most complex part of dental billing: coding and guidelines. Current Dental Terminology, or CDT codes, are what’s used for billing and documenting dental care. These codes were developed by the American Dental Association (ADA) and are reviewed annually for updates; often to accommodate for the adoption of new technologies and procedures. In addition to codes being created, existing codes can be revised or even deleted – making it essential to stay up to date for accurate coding. The ADA website has coding education resources that offer step by step instructions for coding specific procedures.
While a complete list of current CDT codes can always be found on the American Dental Association site, here are some of the more common diagnostic, preventative, and restorative codes you’ll use in day-to-day treatment:
Diagnostic Codes (D0100-D0999)
- D0120: Periodic oral evaluation – established patient
- D0140: Limited oral evaluation – problem focused
- D0150: Comprehensive oral evaluation – new or established patient
- D0180: Comprehensive periodontal evaluation – new or established patient/
- D0210: Intraoral – complete series of radiographic images
- D0220: Intraoral – periapical first radiographic image
- D0251: Extra-oral posterior dental radiographic image
- D0274: Bitewings- four radiographic images
- D0330: Panoramic radiographic image
Preventative Codes (D1000-D1999)
- D1110: Prophylaxis for adults
- D1120: Prophylaxis for children
- D1206: Topical application of fluoride varnish
- D1351: Sealant – per tooth
Restorative Codes (D2000-D2999)
- D2330-D2394: Tooth colored filling – Resin-based composite
- D2740: Crown – porcelain/ceramic substrate
- D2950: Core buildup, including any pins when required
For more dental coding information, be sure to review the ADA’s updated CDT codes list. In addition to the categories listed above, you’ll find codes for endodontics (D3000-D3999), periodontics (D4000-D4999), prosthodontics (D5000-D5899), implant services (D6000-D6199), prosthodontics, fixed (D6200-D6999), orthodontics (D8000-D8999), and adjunctive general services (D9000-D9999).
Dental ICD-10-CM Codes
The International Classification of Diseases, Tenth Revision, Clinical Modification – or ICD-10-CM codes- are diagnostic codes that describe a patient’s medical condition. ICD-10-CM codes help determine the medical necessity of a dental procedure or service. These codes are typically used when required from the insurance payer, or a dental professional performs procedures in an inpatient hospital setting.
While not all dental insurance carriers require the use of ICD-10-CM codes, an increasing number of dental payers do, including Medicaid programs. The contracted payers you work with should specify whether these are required for reimbursement. The National Center for health statistics updates these codes on an annual basis, so it’s important to stay up to date. The CDC has an ICD-10-CM browser tool, that helps providers find updated codes.
When submitting dental claims for reimbursement, insurance companies often require supporting documentation to validate the services provided. This can include treatment notes, X-rays, treatment plans, diagnostic reports, etc. Oftentimes, dental claim denials are a result of missing supporting documentation. To avoid guessing what documentation to submit and when, ensure you’re familiar with the requirements of each insurance payer you’re contracted with. As we’ll discuss next, each insurance payer has their own policies for provider reimbursement.
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Understanding Payer-Specific Policies
Not all dental insurance companies are going to have the same guidelines and reimbursement policies. When contracting with a payer, be mindful of the covered services, fee schedules, and limitations.
Ensure you know what services will be covered by each company so there are no billing surprises down the road. Some may have restrictions or require prior authorization for certain procedures. All of this information can be found in your payer contracting agreement.
Fee schedules dictate the amount insurance companies will reimburse for each dental procedure. And, you guessed it, insurance companies create their own fee schedules. However, providers can negotiate these rates based on comparative rates, patient demand, practice reputation, etc. So, it’s essential to familiarize yourself with each payer’s fee schedule to ensure fair reimbursement before contracting, and accurate filing during.
By familiarizing yourself with the payer specific policies, you can ensure compliance and maximize the reimbursement for the dental services provided.
Coordination of Benefits (COB)
Coordination of benefits, or COB, is a process that determines how multiple insurance plans will work together to provide coverage for a patient’s dental treatment. It ensures that the total insurance benefits received do not exceed the actual cost of the treatment.
To ensure smooth coordination of benefits in dental billing, follow these steps:
- Verify Coverage for Dual Insurances: Determine if the patient has dual dental insurance coverage. Collect all relevant insurance information, including the primary and secondary insurance carriers, group numbers, and policy details.
- Submit Claims to the Primary Insurer: Forward the dental claim to the primary insurer first, following their specific submission guidelines. Include all necessary documentation, such as treatment plans, diagnostic records, and X-rays. Ensure accuracy and completeness to avoid any delays or claim rejections.
- Receive Explanation of Benefits (EOB) from the Primary Insurer: Once the primary insurer processes the claim, they will issue an Explanation of Benefits (EOB). The EOB will outline the allowed amount, the amount they paid, and any outstanding balance.
- Submit the Remaining Balance to the Secondary Insurer: Submit the remaining balance, determined after the primary insurance payment, to the secondary insurer. Include a copy of the primary insurer’s EOB and any additional supporting documentation. Ensure you adhere to the secondary insurer’s submission guidelines and deadlines.
- Follow Up on Claims: Keep track of the claims you’ve submitted to both the primary and secondary insurers. Follow up regularly to monitor claim progress, address any outstanding issues, and ensure timely payment for services rendered.
Common Dental Billing Mistakes
Mistakes in medical billing are bound to happen. However, some dental billing errors have greater repercussions than others. The good news is that dental billing mishaps can be preventable with the right knowledge. Learn more about harmful dental billing mistakes in our blog, Top 6 Illegal Dental Billing Mistakes.
Dental Billing Services
Dental billing software has been heaven-sent to many busy dental practices. Whether you have existing billing staff, or an admin team that wears many hats, software like claims clearinghouses has made dental billing easier and increased reimbursement rates. Here are some of the ways that dental billing software can help with coding alone:
- Easier access to up-to-date procedure codes. Have access to all up-to-date coding information at your fingertips. Don’t know the specific code for a particular service? Easily find the code by simply searching the service description.
- Built in knowledge of payer policies. While it’s true that your payer contracts will include all essential information regarding covered services, fee schedules, documentation requirements, etc., who wants to spend their time searching each contract to answer claim submission questions? When you use a dental billing software like a claims clearinghouse, all that information is built-in and you’re prompted to include the necessary information for accurate submission.
In addition to help with billing codes and guidelines, dental billing software has been known to aid in each step of the healthcare revenue cycle.
About Apex EDI
Apex EDI is a trusted dental claims clearinghouse that specializes in helping dental practices improve their billing efficiency and reimbursement rates. Apex EDI’s comprehensive dental billing software automatically scrubs claims for errors, verifies coding accuracy, and stays up to date with the latest industry standards and regulations – providing dental practices with peace of mind and confidence in their billing processes. To learn more about what Apex EDI can do for your dental practice, schedule a free demo.
If you’re new to billing and need a crash course in billing 101, watch our on-demand Billing Tips & Tricks Crash Course webinar.