FYI

Dentist blog from Delta Dental

Author: Delta Dental (Page 1 of 37)

Claim tips: Dental implants

Implants and the procedures associated with them are not covered benefits under most Delta Dental plans. But when implant services are covered, most denials are because of coding errors rather than a lack of coverage.

Let’s take a look at some common reasons for denials for implants and the procedures and prostheses associated with them.

Prefabricated abutment vs. custom fabricated abutment

Prefabricated abutments and custom fabricated abutments use separate codes:

Prefabricated abutments are machine made and may require modification, while custom fabricated abutments are created by a laboratory process and are specific for an individual application.

Abutment-supported vs. implant-supported crowns

Abutment-supported crowns use a prefabricated abutment (D6056) or a custom fabricated abutment (D6057) to attach a prosthetic crown to the implant body. Abutment-supported single and fixed partial denture crowns require the submission of accompanying abutment codes.

Implant-supported crowns attach directly to the implant body without an abutment. Implant-supported single and fixed partial denture crowns do not require the submission of accompany abutment codes.

The following image contains an example of incorrect coding. In it, the dental office submitted custom fabricated abutments (which are coded D6057) with implant-supported crowns (coded D6065) for teeth #19 and 20. But implant-supported crowns are not attached to the implant with an abutment, so the procedures should have been coded as abutment-supported crowns.

In the following correctly coded image, the dental office submitted custom fabricated abutments (D6057) with abutment-supported crowns (D6058) for teeth #19 and 20 implant supported crowns, which are attached to the implant using an abutment.

If you receive a denial for abutment-supported or implant-supported crowns, it may be one of the following:

  • 161. Benefits could not be determined because of missing/conflicting information
  • 7C2. The submitted procedure is not payable due to the absence or conflict of a related service.
  • 9WA. The fee for this procedure is considered to be part of, and included in the fee for, a completed service.

Single implant crowns vs. fixed partial denture implant crowns

A prosthetic crown that is used to restore one implant is known as a single implant crown. A prosthetic crown that is attached to an implant and is used as a bridge anchor to replace missing teeth is known as a fixed partial denture implant crown.

Here is an example of incorrect coding for these crowns.

ToothCode
#29D6065 (incorrect)
#30D6245
#31D6065 (incorrect)

In this example, the coding is incorrect because the abutments on teeth #29 and 31 are coded as single crowns. For this restoration, the following coding is correct:

ToothCode
#29D6075 (correct)
#30D6245
#31D6075 (correct)

Here, the abutments on teeth #29 and 31 are correctly coded as fixed partial denture crowns.

Natural tooth single crown and fixed partial denture retainer crown codes are often used in error to code implant-supported prosthetics. Instead, they should be coded as fixed partial denture implant crowns.

Incorrect, coded as natural teethCorrect, coded as implants
D6740, #29 (incorrect)
D6056, #29
D6245, #30
D6740, #31 (incorrect)
D6056, #31
D6068, #29 (correct)
D6056, #29
D6245, #30
D6068, #31 (correct)
D6056, #31

If you receive a denial for single implant or fixed partial denture implant crowns, it may be one of the following:

  • 161. Benefits could not be determined because of missing/conflicting information
  • 7C2. The submitted procedure is not payable due to the absence or conflict of a related service.
  • 9WA. The fee for this procedure is considered to be part of, and included in the fee for, a completed service.

Alternate benefits when there is no implant coverage

Delta Dental’s standard plans pay an allowance or alternate benefit towards the cost of implant-supported prosthodontic appliances, subject to the same limitations as standard prosthodontic services. The allowance is based on the fee for a standard pontic procedure. The patient is responsible for any difference in the cost of the implant-supported procedure.

Denial codes for alternate benefits when there’s no implant coverage may be one of the following:

  • FLM. An alternate procedure/benefit has been applied.
  • 503. This service isn’t a covered benefit of the enrollee’s program. An alternate procedure/benefit has been applied.

Implant with natural tooth bridge

When dental implants are covered by a patient’s plan, the fees for the placement of an implant to support a hybrid natural tooth and implant-supported bridge will be denied. Under our guidelines, a fixed partial denture should be retained by either all natural teeth or all implants, not a combination of the two. In the absence of a stress breaker, implant/natural tooth hybrid bridges will be denied. Bridges anchored this way severely stress the natural tooth and the implant and eventually cause bone loss, mobility and bridge failure.

Denial codes for hybrid bridges may include the following:

  • 5A1. The long-term prospects of a tooth must be considered. Under our guidelines, a fixed partial denture should be retained by either all natural teeth or all implants, not a combination of the two.

Congenitally missing teeth

Implant placement will not be considered for the replacement of congenitally missing permanent teeth or for the correction of other developmental or congenital defects resulting in spacing due to migration or drifting of teeth.

Denial codes for congenitally missing teeth implant placement may include the following:

  • 511. Procedures to correct congenital or developmental malformations are not covered.

Associated denials related to implant procedures

X-rays

Pre-operative x-rays depicting each implant site are required to determine the payment of benefits on pre-authorizations. Post-operative x-rays of implant placement are required to determine payment of benefits on paid claims and must depict the entire implant. Implant length, width and location must be appropriate for the clinical condition and allow for adequate function of the implant-supported restoration/prosthesis.

Denial codes for x-rays may include the following:

  • 570. Benefits could not be determined because of missing pre-operative radiographic images.
  • 586. Benefits could not be determined because of missing post-operative radiographic images.
  • 5RX. Benefits could not be determined because the submitted radiograph does not depict the entire tooth.
  • 569. Benefits could not be determined because of the non-diagnostic nature of the radiographic images submitted.

Re-cementation of implant prosthetics

The code D2920 (re-cement or re-bond natural tooth crown) is often used in error to code re-cementation of implant prosthetics. The appropriate implant crown recement codes are as follows:

  • D6092 – Re-cement or re-bond implant/abutment supported crown
  • D6093 – Re-cement or re-bond implant/abutment supported fixed partial denture

Denial codes for re-cementation may include the following:

  • 788. A benefit allowance cannot be made for the requested procedure as our records show that this tooth was previously extracted.
  • 161. Benefits could not be determined because of missing/conflicting information.

Edentulous arches

For a completely edentulous arch, replacement of teeth and restoration of the occlusion can be adequately restored with four to six dental implants.

D6190 – Radiographic/surgical implant index, by report

When your patients’ plans include implant benefits, Delta Dental considers the fee for procedure D6190 to be included in the fee for the definitive treatment for one implant. A separate fee may not be charged to the patient or Delta Dental. Under contracts with implant coverage, procedure D6190 may be covered at the prosthetic benefit level when two or more implants are placed during the same treatment episode. If implants are not covered by the patient’s plan, this procedure is not a benefit, and the patient is responsible for the fee.

Denial codes related to D6190 may include the following:

  • 9WA. The fee for this procedure is considered to be part of, and included in the fee for, a completed service.
  • 7BB. This service is not a covered benefit of the enrollee’s plan.

D6011 – Second stage implant surgery

When implant services are covered by the patient’s contract, Delta Dental considers the fee for this procedure to be included in the fee for procedure D6010, surgical placement of implant body. A separate fee may not be charged to the patient or Delta Dental.

Denial codes related to D6011 may include the following:

  • 9WA. The fee for this procedure is considered to be part of, and included in the fee for, a completed service.
  • 718. This fee for this procedure is considered to be part of, and included in the fee for, a completed service.

D6199 – Unspecified implant procedure, by report

Please provide a narrative report with a complete description of the procedure and its rationale. Tools used, parts, healing caps, etc. will be considered inclusive in the implant procedure and not a separate benefit.

Denial codes related to D6199 may include the following:

  • 564. Submit clinical treatment narrative.
  • 9WA. The fee for this procedure is considered to be part of, and included in the fee for, a completed service.

Delta Dental’s processing policies for implants and the procedures and prostheses associated with them should be considered guidelines. Whenever an exceptional case is involved, please provide a full narrative description and any available supporting documentation to help our staff determine benefits. To ensure timely benefit determination, always submit the appropriate supporting documentation on your initial submission.

Medicare Advantage PPO updates for 2022

It’s a new year, and that means there’s a new crop of partners joining Medicare Advantage. If you’re part of Delta Dental’s Medicare Advantage PPO network, you can see the members of these groups. And if you haven’t opted in, consider this: every year for the next decade, about 10,000 Americans will turn 65. By 2030, approximately 18% of the nation’s population will be 65 or older. Don’t miss out on the opportunity to expand your business by serving this growing market!

Here’s a quick look at the groups joining us for the first time and updating their plans this year.

  • Alignment Health Plan is a new self-funded group with approximately 2,500 members in northern and southern California. Members who choose expanded dental coverage can access the Delta Dental Medicare Advantage PPO network.
  • Aspire Health Plan is backed by Community Hospital of the Monterey Peninsula and Salinas Valley Memorial Healthcare System, bringing coverage to Monterey County in California. Beginning in 2022, certain diagnostic and preventive care benefits will be covered at 100%.
  • CDPHP Medicare serves the Capital Region in New York. In 2022, CDPHP will be expanding to St. Lawrence, Lewis and Jefferson counties.
  • CHRISTUS Health Plan offers Medicare Advantage dental coverage in the state of Texas and select areas of New Mexico.
  • Essence Healthcare serves members in the San Francisco Bay Area. Essence Healthcare was previously known as Stanford Healthcare Advantage.
  • Health Choice Utah offers coverage in all counties throughout the state of Utah.
  • Some Molina Healthcare states are moving outside of our network. In 2022, Delta Dental will be partnered with Molina Healthcare in California, Florida, Michigan, Texas and Wisconsin.
  • Select Health Advantage is available in Nevada in Clark and Nye counties.

Nearly a million members nationwide have access to a Medicare Advantage plan through Delta Dental. By joining the Medicare Advantage PPO network, you’ll enjoy the following benefits:

  • Your practice will be listed in our Medicare Advantage network directory
  • You’ll retain patients who are joining a Medicare Advantage plan. Their fee-for-service plans require that they visit Medicare Advantage network dentists.
  • You’ll grow your business with new Medicare Advantage patients looking for an in-network dentist.

Interested? To apply for participation in the Delta Dental Medicare Advantage PPO network, please email medadv@delta.org. We’ll send you an application and contract.

Is your directory listing helping patients find you?

When was the last time you confirmed your Find a Dentist directory information is correct? It only takes a few minutes, and by making your directory listing as accurate as possible, you’re setting yourself up for success!

Your directory listing is key to helping patients find you. If you’ve recently changed your hours, hired a staff member who speaks a different language or made any other updates, consider revising your listing. You should also confirm all contact information is correct so patients can schedule an appointment.

Here’s how to update your listing:

  1. Log in to Provider Tools and select My account.
  2. Click on Directory profile.
  3. Go to Actions and click Open.
  4. Update your information as needed.
  5. Choose Save as draft if you’re not yet ready to publish your updates or select Publish if you’re ready to go live.

Remember, your listing can and should be revised anytime changes are made to your business. We recommend setting up a yearly reminder to check your listing for accuracy. While you’re at it, be sure to verify your other heavily searched online listings such as YelpFacebookGoogle and Apple.

How to hire and retain a great office team during a staffing shortage

Dentistry is experiencing a significant staffing shortage, and you’ve likely felt the crunch in your own office. A poll conducted by the ADA Health Policy Institute found that more than a third of owner dentists are looking to hire new staff, and more than 80% of those who are currently hiring report that recruiting is extremely or very challenging.

Many offices are dealing with the high stress, fatigue and loss of additional team members that can accompany a long-lasting staff shortage. Unfortunately, experts predict the problem won’t end anytime soon.

Here are some tips for navigating through this tricky time to avoid lengthy and stressful staff shortages in your office.

Be prepared to act quickly

That old management saying, “Hire slow, fire fast,” should be taken with a grain of salt nowadays. Good candidates are out there; they’re just being hired fast. You need to be prepared to screen candidates efficiently and to make an attractive offer to the right hire quickly.

If you wait too long, a good candidate may slip away and accept another position. Consider time-saving steps, such as checking a suitable candidate’s references before an interview takes place so that you can make a job offer right then and there, if a candidate seems like a particularly good fit.

Train current employees

Don’t forget the benefits of taking the time to train the team members you already have. Training and continuing education (CE) units should be a feature of your practice. This not only helps with staff retention and skills, but it also makes your office more attractive to potential new hires.

Studies show higher retention and satisfaction rates among employees where there are training and CE benefits. In addition, training and CE opportunities allow your team members to see that the business cares about them and is interested in their future. That kind of mutuality inspires better morale and lower turnover. Choose the appropriate and applicable courses based on the needs of your practice and the licensing requirements of positions.

In some instances, you may be hiring new team members with fewer skills than you did in the past due to the current crunch. Your practice will need to build systems that can help guide that new staff and also maximize the efficiency and skills of the current team. Training has an important role to play during a staff shortage, so don’t let it lag during this challenging time.

Look to current staff for leads

Your current staff is actually one of your best resources when it comes to finding new staff. Your team members have friends, family members and contacts in the dental industry. With referrals, you can potentially recruit faster by skipping the initial job advertising and resume screening. And referred candidates also tend to be a good fit because they come in knowing at least one person in the office and they arrive with some idea of what the work culture is like. According to CareerBuilder, 88 percent of employers rated employee referrals above all other sources for generated quality of new hires. If you don’t have one already, consider creating an employee referral program to structure and formalize the referral process in your office.

Foster a positive office culture

Getting stressed out and overwhelmed in the middle of a pandemic when staff is short is certainly understandable. But remember, no one wants to work in a chaotic or unpleasant environment for long. Staffing woes will only get worse if your office is not a good place to work. Continue to collaborate with your team on a consistent basis to build a positive, motivated work environment. Build trust in your team through listening and empathy.

When things are hard, patients, staff and dentists are all on edge, but teams value a leader who shows up, listens, stays present and cares. Acknowledge the hard times, and celebrate the good times, like birthdays and holidays. Take a serious look at the environment, team spirit and career paths at your practice, and do what you can to make improvements wherever your office is lacking. A great dental team is the heart and soul of any successful practice, so be sure you’re leading through difficult times with trust and empathy.

Spore test your sterilizers for quality assessment

Monitoring sterilizer functionality is crucial for every office. If your California-based practice has a quality assessment (QA) review coming up, you’ll want to be absolutely certain that you’re properly spore testing all sterilizers on a weekly basis. Improperly sterilized equipment is one of the most common reasons for QA non-compliance.

Spore testing, or biological monitoring, remains the best assurance that sterilization equipment is functioning and that your office is performing instrument processing procedures correctly. Spore testing assesses the killing of highly resistant Geobacillus and Bacillus spores. Inactivation of these microorganisms strongly implies that other potential pathogens in the load have been eliminated.

Here’s a checklist of important points to keep in mind to make sure your practice is safe and compliant when it comes to spore testing sterilizers.

Spore test all sterilizers

You must test all sterilizers present in your sterilization area. If a sterilizer is not currently being used, or is considered a back-up, it still must be spore tested at least weekly. To remain in compliance, store out of use or broken sterilizers away from the sterilization space in your practice if you are not conducting weekly spore testing on them.

Spore test at least once a week

California Code of Regulations states: “Proper functioning of the sterilization cycle of all sterilization devices shall be verified at least weekly through the use of a biological indicator (such as a spore test). Test results shall be documented and maintained for 12 months.”

In addition, the Centers for Disease Control and Prevention and the American Dental Association both recommend sterilizers be monitored at least weekly with biological indicators.

Retain records of spore testing for at least a year

With mail-in services, recordkeeping is done by the monitoring service. During a QA review, the examiner reviews records related to spore testing, so be sure to have them on hand for at least the past 12 months.

Remove any sterilizer with a positive test

If a positive test is reported on a sterilizer, immediately retest the sterilizer using the same cycle that produced the positive result. The sterilizer must be removed from service until you get a passing result from the retest.  Most failed spore tests are due to operator error, so a passed retest confirms that the sterilizer is safe to use.  Remember to document both the failed test and the passing retest in this scenario.

If the retest confirms a positive spore growth, then the sterilizer must remain out of service and all instruments that were sterilized by that machine must be recalled from use and re-sterilized through a different sterilizer to confirm that they are safe for patient care. The broken sterilizer must be inspected, repaired and re-challenged by passing three consecutive spore tests taken on three fully loaded cycles prior to returning the sterilizer to service.

During a QA review, it is not uncommon for an auditor to see failed spore testing results. A failed spore test will not cause a failure of the QA review so long as the office followed and documented the proper protocols after a failed spore test to ensure safe care for patients.

Do not substitute other forms of testing for spore tests

Spore testing is the standard for assuring proper sterilization of dental instruments. Mechanical or chemical indicators can help with the detection of procedural errors or malfunctions, but they do not verify sterility, and they do not replace the need for weekly spore test.

Artificial intelligence and the future of dentistry

With artificial intelligence, or AI, the future of dentistry has arrived. While AI will never replace the personal care and attention you provide your patients, this technology can help you become more consistent and efficient, and can act as an objective second opinion when you’re faced with difficult or ambiguous decisions.

What exactly is AI, anyway?

While AI may conjure images of gleaming robots and sentient computers, the reality is far less dramatic. AI uses computer software to analyze large sets of information and find patterns in them. As it gathers more and more information, it gradually learns to assess situations and then make informed decisions or predict outcomes.

Interesting. So how can AI help me?

AI can improve your ability to detect dental conditions quickly and accurately, and can consistently provide you with appropriate treatments options. So far, AI has proven useful for several applications:

  • Diagnostic dentistry. AI works well for diagnosing dental conditions that may be caused by multiple factors, such as jaw issues and canker sores. Since AI can analyze thousands of x-rays simultaneously, it can help you make objective, consistent diagnoses for issues like cavities. It has also proven useful for identifying patients at risk for developing certain conditions, including oral cancers.
  • Orthodontics. AI has proven useful in various phases of orthodontics, including diagnosis, treatment planning and follow-up monitoring. AI can also help determine a dental plan, including how the patient’s teeth should be moved, how much pressure should be applied to teeth and where the pressure points on specific teeth are. Finally, AI can be used to create precise aligners.

What else can AI help me with?

On the administrative side, AI can help speed up the claims process and help you better serve your patients.

When you submit a claim to an insurance company, the insurance company must determine whether your procedure will be covered. Inconsistency and disagreements during this process can cause frustration and delays, which can in turn lead to frustration and delays in treatment for your patients.

AI can analyze data far more quickly and accurately than a person can. Its ability to make quick, impartial decisions ― particularly when analyzing oral imagery ― takes the ambiguity and human subjectiveness out of the claims process. This brings speed, consistency and reliability to the decision-making process, which means less headaches for you and your patients.

AI can also help insurers detect bad actors to help ensure dental care remains available and affordable for your clients. By being able to examine and compare thousands of x‑rays, AI can quickly detect resubmission fraud and overdiagnosis, and distinguish fraud patterns from honest errors, such as when a dental office mistakenly submits the wrong image with a claim.

This sounds promising. Does AI have any drawbacks?

A few. Much of the dental patient data that AI need to make accurate diagnoses isn’t as available or accessible as some other data because it’s protected or confidential. That means these data sets are often relatively small compared with other datasets used for AI applications and may be incomplete.

Also, the data that is available may result in a bias by the AI program. For example, datasets obtained from hospitals, where patients often visit due to an injury, dental emergency or severe dental conditions, might suggest that patients are sicker than they actually are. Conversely, data from wearable devices such as smartwatches, which are often worn by healthy young people and athletes, might lead the AI to assume that patients are unusually healthy. This bias can also lead to AI overlooking certain groups of underrepresented patients.

Still, the technology shows great potential, and advances in AI promise to make it an integral part of your dental practice. While the technology is still emerging, AI may help you to serve your patients more efficiently, consistently and confidently than ever.

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