Coding: Best practices to avoid fraud

“What does my insurance pay?” This question from patients can trigger loathing and discomfort. Many hygienists may react defensively and believe that a patient is implying he or she won’t accept treatment if it’s not at least partially covered.

There is no specific coding curriculum required in dental hygiene, nor is there a continuing education requirement. This means hygienists often do not know the proper responses to patients’ insurance questions, and defensiveness may not display the caring attitude they’re known for.

Most hygienists would never knowingly perpetrate any type of dental fraud, abuse, or scam. At the same time, patients and others with whom they work may ask if codes can be alternated, treatment dates changed, or other steps taken to increase the dental benefit coverage.

This is more than an ethical dilemma. Hygienists have worked too long and too hard to complete their education and licensure to allow fraud and abuse to jeopardize their careers. Whether it occurs by accident or ignorance, fraud is fraud, and accidental fraud happens. Hygienists need to learn what they can do to avoid accidental fraud. The majority of dental practices and practitioners do what they can to help patients. There is no negative intent. But this does not mean that fraud is not occurring.

You may be thinking, “This doesn’t apply to our practice because we don’t work with dental benefit carriers.” Not correct! Procedure codes are part of every patient encounter, even if the patient has no benefits. Federal regulations and legislation arising from the Health Insurance Portability and Accountability Act (HIPAA) named the CDT code the HIPAA standard code set for dentistry.1

One purpose of the CDT code is to ensure efficient claim processing. But it is also used to populate electronic health records. That means that even if your practice does nothing with third-party reimbursement, your practice is still required to use accurate codes in its documentation.

Myths and inaccuracies

There are many myths, old scripts, and outdated ideas about dental benefits and codes. Without knowledge of the codes and how they are being applied, there is a strong likelihood that you and your office could commit fraud.

The sidebar shares the results of an informal survey I conducted on the DentalCodeology Insiders Facebook page that asked what practicing clinicians describe as their coding pain points. The sidebar contains what some of them wrote in their own words, and their thoughts were shared by their peers.

These pain points are a challenge because many practices have billing systems and protocols that are built on a series of myths and misunderstandings. Staff read about them in articles, hear about them from speakers and insurance carriers, learn about them from salespeople, and more. Just as dental hygienists have no required curriculum for coding, neither do some of those who are most often responsible for this important task.

A significant amount of fraud is not caught. It has been argued that if something has been done a certain way for a long time and no one catches it, it must be OK. This is not the case. Fraud by accident or ignorance—and even if it’s not caught—is still fraud.

Coding pain points often stem from confused and convoluted interpretations of three key terms: fees, codes, and coverage. Clarifying the relationships and differences between them can help clear up the confusion.

• Fees—A practice can choose what fees to charge. Practice fees should be based on the cost of doing business plus a reasonable profit. Routine analysis of cost helps ensure that your practice is functioning efficiently and effectively.

• Codes—The CDT codes support uniform, consistent, and accurate documentation of the services delivered. Reimbursements are tied to outcomes in the future. Having a code provides the measurement tool (metric) and the opportunity to measure outcome data.

• Coverage—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 benefit carriers. All of these are also contract negotiations. Coverage or noncoverage is not based on the whim of a third-party carrier; it is based on those contracts.

Best practices

For many, there could be better ways—best practices that could help hygienists learn their roles and responsibilities in coding. This will lead to the practice coding more effectively, thus increasing claim approvals, leading to more efficient collections, and reducing the possibility of fraud.

No. 1 best practice: The most accurate code

As professionals, our coding role is to use the most accurate code to describe the procedure performed. Coding for what you do is a fundamental rule. Many practices have experienced third-party payer remapping (down-coding) of their submissions. Carriers do not automatically change a dentist’s submitted procedure code to a less complex or lower-cost code. This is determined by the policy language.

Carriers can change a code, but professionals cannot. You may ask why this is. Carriers can change a code 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.

This has been discussed many times with regard to alternating codes D1110 and D4910. Mark Rubin, JD, legal counsel for the American Dental Association, said, “Knowingly alternating D1110 and D4910 to maximize insurance benefits constitutes fraud. We must code for the procedure being performed. By doing otherwise, the attorney general could make a convincing case for prosecution.” Treatment should be based on clinical need, not on covered services.

Another example that dental hygienists can relate to is D4346 vs. D1110/D1120. Code D4346 was created to fill a gap in coding. As hygienists, we have been well aware of the gap for many years. It has been two years since D4346 code was added in CDT 2017. Yet there is still a great deal of confusion about it. The D4346 code addresses the procedure that lies between a prophylaxis and a scaling and root planing.

Here is an equation:

• Localized inflammation <30% teeth = D1110/D1120

• Generalized inflammation >30% teeth = D4346

• Periodontitis = D4342/D4341

As noted, practices must use the code that most accurately describes the care rendered. When a practice specifically chooses to use code D1110/D1120 vs. D4346 for the purpose of maximizing benefits, as Mr. Rubin states, there could be a case for prosecution. The takeaway? Fraud by accident, ignorance, or changing codes to increase benefit payment is fraud. The following best practice—documented diagnosis—can clear up the coding challenges with D4346.

No. 2 best practice: Documented diagnosis

Through education and experience, dentists diagnose a patient’s oral health prior to treatment-plan preparation and delivery of necessary services. Oregon and Colorado became the first states to allow hygienists to specifically authorize the dental hygiene diagnosis (DHD)2 as part of dental hygienists’ scope of practice.

The DHD is not limited to these states. All hygienists as part of their educational background were trained to make a DHD. The DHD identifies an individual’s health behaviors, attitudes, and oral health-care needs for which the dental hygienist is educationally qualified and licensed to provide. The DHD requires evidence-based critical analysis and interpretation of assessments, and provides the basis for the dental hygiene care plan and an important piece in the diagnosis made by the dentist.

This is a best practice in action and moves professionals in the direction that will be required in the near future. The diagnosis codes reported on the claim with the service rendered are to provide justification to a payer as to why a service was performed and can determine the medical necessity of the procedure.

Medical necessity is the concept that health-care services are necessary and appropriate for the evaluation and management of a given disease, condition, illness, or injury. The care provided must be considered reasonable when judged against current standards of care. The documentation must support the level of care.

This is not limited to medical cross-coding. Both the ADA claim forms and the HIPAA standard electronic claim transactions are able to report up to four diagnosis codes per dental procedure in Box 34A. Routinely documenting the diagnosis and supporting information can significantly reduce rejections and requests for more information. It also reduces fraud because the selected treatment is based on the diagnosis.

No. 3 best practice: Lifelong learning and training

Creating and revising codes to embrace new technologies, materials, and procedures leads to earlier arrest and prevention of oral disease and positively influences systemic health. To adapt to a fast-moving world, CDT is now updated every year.

Initial coding training and retraining should be required in all practices. A minimum of one or two office staff meetings each year should be reserved for coding updates and training. Practice profitability can be increased when staff has up-to-date coding knowledge.

Reducing the risk with DentalCodeology

For years I’ve watched my fellow dental hygienists’ frustration when it comes to all things insurance. Our education grounds us in so much, yet coding is a missing piece. There are two licensed dental professionals in most states—the dentist and the dental hygienist. Though there is no intent to commit fraud, it happens often, and the greatest risks are to the licensed professionals.

Pain points are real. The good news is that there are answers. Solving those and many other pain points is part of my mission. The mission of DentalCodeology is based on three pillars: (1) I believe we can have a world with no oral cancer, (2) I believe we can meet the 2020 goal of the World Federation of Dentistry to have a caries-free world, and (3) I believe we can cure, not just manage, periodontal disease.

The DentalCodeology Consortium, a division of the DentalCodeology Insiders group, created and submitted 19 requests for additions and changes to the CDT book for 2020. The DentalCodeology Insurance Navigator Method (dentalcodeology.com/learning-center/)was created to fill hygienists’ education and training gaps.3 It is a self-directed online curriculum and the first of its kind aimed directly at clinicians. Hygienists can be grounded in accurate knowledge and know how to respond when their patients ask, “What will my insurance cover?”

The world moves much faster than it did just five or 10 years ago. There’s more competition than ever. It’s easy to fall behind. Coding competency is extremely important in a practice’s revenue cycle and employability. Continuous learning is the key to success and fraud avoidance.