FYI

Dentist blog from Delta Dental

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Upcoming webinars for May: Provider Tools and Community Care Network

Here’s a great way to make your office more productive and find new patients ― for free! Check out our upcoming series of webinars to learn how Provider Tools can work for you and how you can expand your client base while you support your local Veteran community with the Community Care Network.

Provider Tools webinars

You can learn how to verify coverage, submit claims online, enroll in direct deposit and more by attending our Provider Tools webinars.

Here’s the schedule for May’s Provider Tools webinars:

Tuesday, May 3, 11 a.m. PT / 2 p.m. ET

Wednesday, May 11, 9 a.m. PT / noon ET

Thursday, May 19, 9 a.m. PT / noon ET

Tuesday, May 24, 11 a.m. PT / 2 p.m. ET

If you have a question that’s not answered in our webinar, you can schedule a video call with us. And we’re happy to address any specific topics in the webinars. Just send us an email at providertools@delta.org.

Community Care Network webinars

The Department of Veterans Affairs’ Community Care Network (CCN) is the new health care network for Veterans. This network provides a terrific opportunity to attract new patients while providing dental care to those who served our country.

Learn more about this network by attending one of our webinars:

Wednesday, May 4, 11 a.m. PT / 2 p.m. ET

Wednesday, May 11, 11 a.m. PT / 2 p.m. ET

Wednesday, May 18, 11 a.m. PT / 2 p.m. ET

Wednesday, May 25, 11 a.m. PT / 2 p.m. ET

Why your claims with x-rays are being denied and what you can do

Some procedure codes require the submission of documentation with claims for Delta Dental PPO™ and Delta Dental Premier® patients. Let’s review radiographic image requirements for common procedures and the associated denials that can occur.

Crowns

Pre-operative and periapical (depicting the apex) radiographic images are required when submitting crown procedures D2710 through D2794. Do not substitute a panoramic radiograph to replace periapical images. Radiographs must show the endodontic and periodontal state of the tooth and must be taken within one year of the crown prep procedure.

Photographs must accompany radiographs when evidence of necessity is not obvious on the radiographs.

Lab slips should be maintained as part of the patient record.

In this example, the following radiographic images fail to depict the entire tooth. Pre-operative radiographic images must show the apex (tip of the tooth’s root) and are requested to rule out associated periapical pathology.

In comparison, the following radiographic image correctly depicts the apices of the submitted teeth.

Common reasons for crown denials

Core buildup, including any pins

Periapical radiographs taken within one year of the planned treatment are required when submitting core buildup and post and core procedures D2950 through D2957.

Do not substitute a panoramic radiograph to replace periapical images.

A narrative is also required. Per the American Dental Association, build-ups should not be reported when the procedure only involves a filler to eliminate any undercut, box form, or concave irregularity in the preparation.

Common reasons for core buildup denials

  • 570. Benefits could not be determined because of missing pre-operative periapical radiographic images.
  • 5L8. Benefits could not be determined because of missing pre-operative periapical 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.
  • 564. Submit clinical treatment narrative.
  • 5BU. The fee for buildups is included in the fee for the completed restoration unless there is extensive loss of tooth structure.

Endodontics

Pre-operative and post-operative periapical radiographs are required when submitting endodontic procedures D3310 through D3330 and D3921. All radiographs, including working radiographs, should be maintained in the patient treatment record.

The following radiographic image fails to depict completed root canal therapy on the submitted teeth.

In contrast, the following radiographic images correctly depict an acceptable pre-operative periapical x-ray and post-operative x-ray of completed root canal therapy on the submitted tooth.

In this second example, the following radiographic images correctly depict an acceptable pre-operative periapical x-ray and post-operative x-ray of completed root canal therapy on tooth #19.

If your endodontic claim is denied, you may see one of the following denial codes:

  • 570. Benefits could not be determined because of missing pre-operative periapical radiographic images.
  • 5L8. Benefits could not be determined because of missing pre-operative periapical radiographic images.
  • FMW. Benefits could not be determined because of missing pre- and post-operative periapical images.
  • 8L9. Benefits could not be determined because of missing post-operative radiographic images of completed root canal therapy.
  • 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.

Periodontics, including scaling and root planning

When submitting periodontic procedures D4210 through D4212, D4240 through D4245, D4260 through D4285, D4341 through D4342 or D4381, you must include bitewing radiographs taken within 12 months of the planned treatment that show both arches of bone levels. Furthermore, loss of alveolar crest height beyond the normal 1-1.5-millimeter distance to the cementoenamel junction (CEJ) must be evident on radiographs. Periapical or panoramic radiographs can only be substituted when bone loss exceeds levels that can be captured in a vertical bitewing.

Other requirements include periodontal charting (probing) completed within the past 12 months, periodontal case type and diagnosis with detailed clinical chart notes regarding the necessity of the periodontal treatment.

The following bitewing x-ray is nondiagnostic, as the interproximal contacts are overlapped and fail to show bone loss. 

Compare this to the following bitewing x-ray, which depicts both appreciable bone loss and calculus. 

Common reasons for periodontic denials

  •  Benefits could not be determined because of missing full-mouth radiographic images. (Note: This code may also be used to request bitewing x-rays.)
  • 5F5. Submit dated pre-operative diagnostic radiographs, current periodontal chart, dated appointment schedule and clinical treatment notes. 
  • 426. Benefits could not be determined because of missing radiographic images, periodontal charting and treatment record.
  • 5GB/5GC. Submit current periodontal chart, dated pre-operative diagnostic radiographs and a copy of the patient treatment record.
  • 574. Benefits could not be determined because of missing periodontal charting.
  • 569. Benefits could not be determined because of the non-diagnostic nature of the radiographic images submitted.
  • 5GJ. Submit dated copy of the original treatment notes.
  • 5F8. Submitted documentation fails to support payment of benefits for scaling and root planing.

Crown lengthening

Pre-treatment bitewing radiographs taken within 12 months of the planned treatment are required when submitting for the crown lengthening procedure (D4249).

A detailed clinical narrative is also required.

When procedure D4249 is performed on the same day as the preparation/placement of the crown, a separate fee for procedure D4249 may not be charged to the patient or Delta Dental. Prior to final restoration of a tooth, a minimum of four weeks must be allowed following clinical crown lengthening.

Common reasons for crown lengthening denials

  • 573. Benefits could not be determined because of missing full-mouth radiographic images.   (Note: This code may also be used to request bitewing x-rays.)
  • 564. Submit clinical treatment narrative.
  • 569. Benefits could not be determined because of the non-diagnostic nature of the radiographic images submitted.
  • 9WA. The fee for this procedure is considered to be part of and included in the fee for a completed service.

Implant supported prosthetics

You are required to include current periapical radiographs, including the apex of the implant body and surrounding bone, when submitting for implant-supported prosthetic procedures D6055 through D6077, D6082 through D6088, D6094, D6097 through D6099, D6110 through D6123 and D6194 through D6195. 

Do not substitute a panoramic radiograph to replace periapical images. Pre-operative x-rays depicting each implant site are required to determine payment of benefits on pre-authorizations. We must receive post-operative x-rays of implant placement to determine payment of benefits on paid claims. These x-rays must depict the entire implant.

Photographs, if available, may also be submitted for review.

For example, the following panoramic radiographic x-ray is nondiagnostic. It fails to clearly depict implant placement at site #9. Do not substitute a panoramic radiograph to replace periapical images.

The following post-operative periapical x-ray, however, correctly depicts the apex of the implant body and surrounding bone.

Common reasons for implant-supported prosthetic denials

  • 570. Benefits could not be determined because of missing pre-operative periapical radiographic images.
  • 5L8. Benefits could not be determined because of missing pre-operative periapical 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.

Fixed prosthodontics (bridge abutment crowns)

When submitting for fixed prosthodontic procedures D6710 through D6794, you are required to include pre-operative periapical radiographs that show the current endodontic and periodontal state of the tooth. These x-rays must be taken within one year of the crown prep procedures. Do not substitute a panoramic radiograph to replace periapical images.

Photographs, if available, may also be submitted.

Lab slips should be maintained as part of the patient record.

In this example, the radiographic image is nondiagnostic, as it fails to clearly depict the submitted abutment teeth.

In comparison, the following radiographic images for proposed bridge 13-15 clearly depict abutment teeth #13 and #15.

Common reasons for fixed prosthodontic denials

  • 570. Benefits could not be determined because of missing pre-operative periapical radiographic images.
  • 5L8. Benefits could not be determined because of missing pre-operative periapical 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.

Oral surgery (impacted tooth)

Current periapical or panoramic radiographs are required when submitting oral surgery procedures D7210 through D7241 and D7251. Radiographs are necessary to evaluate conditions detected by history and clinical examination and are essential to detect, diagnose, and treat conditions that otherwise may be difficult to identify.

Further, as the classification of impactions is based on the anatomical position of the tooth rather than the surgical technique employed in removal, preoperative radiographs should be maintained in the patient treatment record.

Detailed, tooth specific clinical chart notes regarding the necessity of the treatment and photographs, if available, should be submitted.

The following panoramic x-ray clearly depicts the anatomical position of the third molars.

Common reasons for oral surgery denials

  • 570. Benefits could not be determined because of missing pre-operative periapical radiographic images.
  • 5L8. Benefits could not be determined because of missing pre-operative periapical radiographic images.
  • 5T2. Benefits could not be determined because of missing pre-operative panoramic radiographic image.
  • 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.

General tips for submitting x-rays

To expedite the processing of your claim and to ensure timely benefit determination, always submit the appropriate mounted and dated x-rays and supporting documentation on your initial submission. Enter the required documentation information in the “Remarks” or “Comments” field of the claim.

You can refer tothe Submission Requirements table, which is located on pages 4-1 through 4-3 of the 2022 Claims Processing Policies and Procedures Handbook, to identify the necessary documentation and clinical information required for review of specific procedure codes.Please refer to the specific procedure code in the handbook for more details regarding the description of procedures.

Please do not submit original radiographic images if they are the only diagnostic record for your patient. Duplicate radiographs or radiographic image copies of diagnostic quality, including paper copies of digitized images, are acceptable. We do not return radiographic images or other documentation submitted with paper claims; however, we will make an exception when we receive a stamped, self-addressed envelope with the claim.

During clinical review of claims and pre-treatment estimates, Delta Dental reserves the right to request radiographic images and documentation for procedures that otherwise may be identified as not requiring the submission of documentation.

CDT coding and nomenclature are the copyright and a trademark of the American Dental Association, all rights reserved.

How to serve non-English speaking patients

The U.S. is more of a melting pot than ever, with about 350 languages currently being spoken, according to the latest census statistics. That means more people may be coming into your practice who may have difficulty communicating with you.

What can you do to help patients with limited English proficiency? You can receive free language assistance for Delta Dental members through our Language Assistance Program (LAP). LAP gives you access to interpretation and translation assistance that meets state and federal requirements for language assistance services.

Request interpretive services

You can get interpretive services in 170 different languages through LAP. This service is available to Delta Dental members at no charge and allows you to talk to patients through an interpreter so you can understand their needs clearly and give them the best care possible. For phone interpretation, just call 866-530-9675 to get an interpreter the next time you need one.

If you prefer to talk with a patient face to face, an interpreter can also meet you in your office and translate any conversations you have. Live interpretation services require 72 hours’ notice.

Get member materials

Members can access information about our plans and benefits in different languages, too. The Delta Dental website is available in Spanish, and members can learn about the different plans and benefits as well as read articles on dental health and wellness.

Plan materials can be translated into other languages and made into accessible formats such as Braille and audio files upon request.

Spread the word

If you or someone in your practice speaks another language, it’s worth advertising this fact. Make sure your dentist directory listing includes the languages spoken at your practice. This can help patients who speak your language find you easily.

Create a welcoming environment

You can do even more to welcome patients who don’t speak English. Create a protocol for your staff to follow when talking to patients with limited English proficiency, and make a conscious effort to be aware of and respect cultural differences.

If you have a large number of patients who speak a specific language, make sure your policies, brochures and forms are available in that language.

Patients with limited English proficiency may feel uncomfortable at first, but if you create a warm, welcoming environment and help them overcome the language barriers, you’ll serve them better and grow your practice at the same time.

On-site quality assessment review checklist for 2022

In California, the Department of Managed Health Care (DMHC) requires that all dentists receive yearly on-site quality assessment (QA) reviews. These reviews evaluate how the many components of your practice compare to the expectations of dental professionals, regulatory agencies, dental educators and Delta Dental.

Your QA review will focus on two parts of your practice:

  1. Structural (about 20 minutes). Review of your facility and equipment, as well as emergency, sterilization and infection control protocols.
  2. Records (about an hour and 45 minutes). Review of patient treatment documentation for relevance and acceptability under current standards of patient care.

The easiest way to prepare for an on-site assessment is by getting acquainted with the aspects of a QA review. Follow the checklist below to understand what will be checked during your assessment.

Structural review

The structural review involves an assessment of the facility and equipment, as well as sterilization protocols.

Facility and equipment

  • Facility is clean and well maintained.
  • Dentist name and office hours are posted.
  • Procedure manual includes protocols for appointments, complaints, broken appointments and specialty referrals.
  • Accommodations exist for patients with disabilities, such as wheelchair access and a grab bar in the restroom.
  • Waterlines have anti-retraction valves installed and are maintained with properly flushed handpieces.

Radiology

Sterilization and infection control

  • Staff is trained in infection control standards, and procedural logs are kept.
  • Gloves, masks, protective attire and eyewear are used appropriately.
  • Weekly biologic monitoring is conducted and records are kept.
  • Instruments and handpieces are properly sterilized, stored and labeled.

Safety and emergency procedures/equipment

  • Drugs, syringes and needles are properly stored, and a log is kept of drugs dispensed on site.
  • Required certifications are up to date.
  • A modern evacuation system exists for nitrous oxide.
  • Written office protocol includes staff responsibilities for evacuating patients in emergencies or natural disasters. The evacuation plan with clearly marked exits is displayed.
  • An active contact system can reach the dentist 24/7.
  • A portable emergency oxygen is available, full and there is a positive pressure valve and/or Ambu bag; staff are trained in its use.
  • Mercury hygiene and safety requirements are observed.
  • Medical emergency kit is up to date.

Records review

The records review involves a review of your patient care documentation.

Medical and dental history

  • Medical history forms include yes/no questions, identify patient’s existing conditions and contain comprehensive health information.
  • Dental history includes baseline information, TMJ/occlusion status, appliances, periodontal condition and results of soft tissue/oral cancer exam.

Treatment notes

  • Progress and treatment notes are legible and in ink.
  • Included, as appropriate, are: 
    • Referrals to specialists
    • Records forwarded or received
    • Anesthetic used (type, amount and concentration of any vasoconstrictor)
    • Medications prescribed
    • Laboratory instructions

Quality of care

  • Professionally acceptable standards of care are observed for: 
    • X-rays — adequate number, appropriate frequency, of diagnostic value, mounted and labeled
    • Treatment plan — in ink, consistent with diagnosis and exam findings, alternative and elective treatment documented with the patient’s choice and reason
    • Treatment sequence — in order of need
    • Informed consent — documentation that treatment plan was reviewed and patient understands risks, benefits, alternatives and costs; any refusal of recommended care is documented

Outcomes of care

  • Patient records demonstrate effectiveness of preventive care.
  • Overall comprehensive documentation demonstrates that treatment was provided as appropriate, including: 
    • Good prognosis for appropriate longevity
    • Evidence of need (x-rays, pocket charting, etc.)
    • Minimal unplanned treatment or retreatment
    • Referral to a specialist in a timely manner
    • Post-operative instruction given
    • Follow-up (pocket charting, x-rays, etc.)

After your review, you’ll be notified of the findings by mail. If you fail any part of the inspection, you’ll be asked to respond to show that you’ve corrected the error. Outstanding errors or repeated failures on follow up inspections may result in a referral to Delta Dental’s Peer Review Committee (PRC).


This list highlights just a few aspects of a QA review and is a useful tool to help you review your practice through the eyes of the QA examiner. Please refer to the Quality Management section of the Delta Dental Dentist Handbook for information on the Quality Assessment process and a list of all requirements. Together with your staff, you can evaluate your office policies and procedures and be even better prepared for a future on-site QA review. For more posts about QA reviews, check out the quality assessment category.

Let us know when there are changes at your practice

Running a practice can be hectic, and it’s easy for details to slip through the crack. However, it’s essential to let us know about changes like a retirement, a practice name change or new dentists on staff.

What changes does Delta Dental need to know about?

Per the terms of your contract, please make sure to notify Delta Dental of any changes to the following information, ideally 30 days prior to the change if possible:

  • New practice name
  • New office location or primary phone number
  • Change of address
  • Tax ID changes (your W-9 is required for us to process any tax ID changes)
  • Sale or closure of practice
  • Dentists joining or leaving a practice location (contact us to request an application for network participation)

How do I let Delta Dental know about these changes?

Forms for reporting these changes are available at our website. Once you’ve submitted the necessary forms, we may contact you to verify the information before we update our records.

What else do I need to know?

Once you’ve submitted an administrative form, you generally don’t have to take any extra steps. However, there are a few things to know about the process.

  • It takes about four weeks processing time from the date we receive your form for the changes to be reflected in our system. You’ll receive confirmation of the effective date from the Provider File Maintenance department.
  • Until our systems are updated, claims will continue to be processed with the information on record.
  • The processing time for dentists in Maryland is no more than 15 working days after we receive your administrative form.

Thank you for helping us keep our records up to date! We’re proud to be your partners in ensuring that your patients get great care and that you get paid quickly and effortlessly for the work you do.

A guide to screening patients for oral cancer

If you take five minutes during an oral exam to check a patient for oral cancer, you could save a life.

In 2021, some 53,000 Americans were diagnosed with oral cancer, according to the Oral Cancer Foundation. This number has steadily risen over the last decade, and the COVID-19 pandemic has raised the risk even more.

A study in the Journal of the American Dental Association found that tobacco and alcohol use has risen during the pandemic. Weight gain, poor diet and oral hygiene and a lack of treatment over the past two years have also increased the risk.

If you aren’t already screening your patients, now’s a good time to start. As with most cancers, early detection is a key to survival. If oral cancer is diagnosed at an early stage, the five-year survival rate is 85%.

Who’s at risk for oral cancer?

Oral cancer can include cancers in the gums, tongue and back of the throat. It occurs most often in people over the age of 40. Risk factors for oral cancer include tobacco and alcohol use, prolonged exposure to the sun and infection with certain types of the human papillomavirus (HPV). More men than women are diagnosed with it.

What are the symptoms of oral cancer?

The best way to diagnose oral cancer is by performing a quick but thorough screening as part of a patient’s regular exam. Look for:

  • A sore in the mouth that doesn’t heal
  • A white or red patch in the mouth or on the lip or tongue
  • A sore throat or a feeling that something is caught in the throat
  • Difficulty chewing, swallowing, or speaking
  • Difficulty moving the jaw or tongue
  • Swelling in the jaw that causes dentures to fit poorly or become uncomfortable
  • Numbness in the tongue or other areas of the mouth
  • Voice changes
  • A lump or mass in the neck
  • Ear pain

The Centers for Disease Control and Prevention recommends checking the following areas of the mouth for signs of cancer:

  1. Lymph nodes. Check the nodes in the neck and under the lower jaw.
  2. Cheeks and lips. Look for red or white patches.
  3. Gums. Notice any lumps or spots.
  4. Tongue. Pull the tongue forward and look for any swelling or abnormal color or texture. Also check the base of the tongue and underside.
  5. Palate and back of throat. Look for any abnormalities.
  6. Floor of the mouth. Check for lumps or sensitivity.

Conducting these exams not only saves lives, but it can also help protect you against malpractice. Patients will appreciate the extra care you take. Take the five minutes. Your patients will thank you.

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