ADA GUIDELINES, CODING, & BENEFITS FOR RADIOGRAPHS
Coding for radiographs is not complicated; however, payment typically is. Know the guidelines & limitations...
Coding for radiographs is not complicated; however, payment typically is. Know the guidelines & limitations to communicate more effectively with patients & minimize problems of reimbursement.
by Carol Tekavec, CDA, RDH
When the American Dental Association issues guidelines for any dental treatment or service, they are typically accompanied by phrases such as “guidelines are not substitutes for a clinical examination.” Despite this, ADA guidelines are usually respected as reasonable directives for treatment by members of the profession, as well as the insurance industry.
In 2005, the ADA and the FDA issued a document titled “Guidelines for Prescribing Dental Radiographs.” It is a graph of categories of patients joined to possible appropriate radiographs, along with a listing of clinical situations where radiographs might be recommended. View these guidelines at www.ADA.org.
Another document, this one from the ADA and the U.S. Department of Health and Human Services - “The Selection of Patients for Dental Radiographic Examination - 2004” - provides additional direction for patient selection. According to this document, “These guidelines can be used by the dentist to optimize patient care, minimize the total diagnostic radiation burden, and responsibly allocate health-care resources.” The guidelines are further described as providing a format for appropriate clinical practice concerning radiation, using the ALARA Principle (As Low As Reasonably Achievable) to minimize the patient’s exposure to radiation. Examples of good practice include:
- Use of the fastest image receptor compatible with the diagnostic task
- Collimation of the beam to the size of the receptor whenever feasible
- Proper film exposure and processing techniques
- Use of leaded aprons and collars
In addition, the guidelines also state: “Radiographic screening for the purpose of detecting disease before clinical examination should not be performed. A thorough clinical examination, consideration of the patient’s history, review of any prior radiographs, caries risk assessment, and consideration of both the dental and general health needs of the patient should precede radiographic examination.”
In plain language, this means that a patient should not have radiographs exposed until after a dentist has performed an examination and decided what radiographs should be taken. This makes good sense from a practice-management standpoint. Patients often object to being subjected to “routine” radiographs, without an appropriate and communicated reason.
Worse yet is a new patient who has been scheduled for a “new patient exam and “cleaning” with a hygienist, as well as an exam with the dentist afterwards. If the patient is taken for radiographs prior to the “cleaning,” a discussion is often required to explain the need for “routine” radiographs. The patient protests and the hygienist insists. If the radiographs are successfully exposed, then the patient is taken to the treatment room for a “cleaning.” If the hygienist discovers that this patient has elaborate deposits, bone loss, or requires root planing, further problems arise. Fee issues, time issues, and trust issues all erupt. If the dentist arrives at this point to perform an exam, very often he or she will encounter a resistant or even hostile patient. This situation is not conducive to a satisfied patient receiving appropriate treatment in a timely manner while paying his or her bills on schedule!
It is much better, from every aspect of patient care and practice management, to allow the dentist to examine the patient prior to any radiographs, and if at all possible, prior to any appointment for hygiene services. The patient accepts the radiographs ordered by the dentist as being necessary for him, plus the dentist diagnoses what “type of cleaning” the patient actually needs. An appropriate treatment conference with a written estimate and discussion and documentation of informed consent can also be accomplished in advance of hygiene and restorative treatment. This format greatly simplifies fee issues, time issues, and trust issues.
After the dentist’s evaluation of the patient, what are the current ADA guidelines for radiographs? Here are a few highlights:
- Child with transitional dentition (after eruption of the first permanent molar) → Recall patient with no clinical caries or not at increased risk for caries: posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe.
- Child with transitional dentition → Recall patient with clinical caries or at increased risk for caries: posterior bitewing exam at six- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe.
- Adult → Recall patient with clinical caries or at increased risk for caries: posterior bitewing exam at 6- to 18-month intervals.
- Adult → Recall patient with no clinical caries and not at increased risk for caries: posterior bitewing exam at 24- to 36-month intervals.
Thirty-six months between bitewings for healthy adult patients with no risk factors for caries is quite a substantial amount of time. Does this mean that bitewings may not be taken more frequently? No. The frequency rate is subject to the clinical judgment of the dentist. Does this mean that dental plan contracts may list three years as a payment guideline for bitewings? Yes. When guidelines such as these are published, they provide justification for contract limitations.
To avoid problems with patients and insurers, as well as to mitigate possible malpractice issues, it is essential that the patient’s record contain the reasons why radiographs are being exposed and what was revealed by them. For example, “Suspected interproximal decay maxillary and mandibular left. Interproximal decay discovered on No. 3 and No. 19.” If no decay was observed, the entry might be, “No decay seen at this time. Take another set of four bitewings at next recall to check for decay No. 3D and No. 19M.”
Obviously, it is inappropriate to expose radiographs simply because the patient’s plan covers them “so many times a year.”
Coding for radiographs is not complicated, but payment typically is. What follows are commonly used codes and commonly observed dental contract limitations. Keep in mind that limitations in the contract should not impact the recommendations of the dentist. Knowing potential limitations simply helps us communicate with our patients and minimize any problems that can arise from denials or inflammatory language in the Explanation of Benefits.
- D0274 - Bitewings - Four Films - Most carriers will cover these once annually.
- D0277 - Vertical Bitewings - Seven to Eight Films - Despite the fact that the ADA description indicates that the code is not for a full-mouth series, many carriers regard it as such. A benefit will usually apply, but most carriers recode the service and “use up” the full-mouth series code, D0210-Intraoral - Complete Series (Including Bitewings). D0210 is typically paid once every three to five years.
- D0330 - Panoramic Film - This is usually covered once every three to five years. If completed on the same date as D0210 - Intraoral Complete Series, typically no additional benefit will apply. Many carriers consider a D0330 to be equivalent to a D0210.
- D0210 - Intraoral - Complete Series (Including Bitewings) - Typically this is covered once every three to five years. However, if a benefit has been paid by a carrier invoking this code to apply to D0330, D0277, or for any other combination of periapicals or BWS, then subsequent claims for D0210 will be denied during that time period.
Insurance restrictions on payment for radiographs vary so much that it is extremely difficult for a dental office to anticipate the level of reimbursement available to a given patient. It is usually best to let patients know in advance that the radiographs being taken are necessary for a proper diagnosis, and that their insurance may or may not cover the cost. Reimbursement should never dictate procedures.
For more information about radiographic guidelines, visit the ADA.org Web site. To read a brochure that describes the limited nature of dental insurance, go to “My Insurance Covers This ... Right?” at www.steppingstonestosuccess.com.
About the Author
Carol Tekavec, CDA, RDH, is a practicing dental hygienist, author of the Dental Insurance Coding Handbook - 2005-2008, the designer of a dental chart endorsed by the Colorado Dental Association, and president of Stepping Stones to Success. She has appeared at all major dental meetings and is a presenter for the ADA Seminar Series. Contact her by phone at (800) 548-2164 or visit her Web site at www.steppingstonestosuccess.com.