Dr. Sidney Whitman

150th Anniversary Honorees

Dr. Sidney Whitman is being honored by Mercer Dental Society for his Exceptional Performance. Check out NJDA's full list of honorees.

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​Dental News and Notes

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July 7, 2019

Perils and pitfalls of Insurance coding….stand your ground! What to do when the Insurance Carrier recommends codes…Who Do YOU TRUST?

I recently received an email “Tip Of The Day” from a very popular successful dental consulting group.  The last line reads “…If you’re having trouble understanding which codes to use for insurance, simply contact the insurance company…“The insurance company will tell you the correct code and the rules for using that code so you can be efficient and effective in the future.”……I read it, then re-read it, then scratched my head and then read it once again.  Each time my blood pressure went up a very unhealthy few points.  WHAT???

This is a very well-respected group

This can’t be what I’m reading

This is crazy!

I want to scream “stop the insanity” but only Irene can hear me.

Fast forward two weeks …

I’m thinking, I must be hyper aware; maybe it’s my imagination, but lately it seems that I have had a lot of offices call to complain that Dental Benefits Carriers are advising the dental office and/or patient which codes to submit or re-submit.  This sounds like a logical approach, the customer service agents are trying to be helpful….so why does this get my blood pressure up so much you might ask?

Well if you have to ask me that question, then it’s a good thing you are reading this.  First – in “the world according to Joan,” insurance carriers should NEVER be telling you or your patients what codes to submit.  Your codes should reflect the service you provide.  The claim form is a legal document.  You are on the hook for anything that goes on that form.  If the code you submit is inconsistent with the service you provide or inconsistent with the documentation in your patient record, there are a range of negative things that may transpire; from requests for overpayment to misrepresentation and fraud.

The descriptor language for each code is crucial in making sure you are reporting properly and accurately.  So buy a CDT book or call NJDA.  Next year there will be 37 new codes, 5 revised and 6 deleted codes.  The descriptor language may be a game changer in when and how you report the code.

Let’s think positive.  How nice that customer service agents are trying to help.  They frequently field calls from frustrated patients when something isn’t covered by their plan.  They try and offer some constructive guidance to calm the patient down.  If something wasn’t covered, then surely the dental office must have done something incorrectly.  Of course, the fact that your plan is very specific about when something is covered and what services are covered has nothing to do with the denial.  Obviously your dentist should just re-submit with a different code and you will likely be reimbursed……..cough cough.   Well here is my problem with that:

Codes should be based on medical necessity and what service you provide

Services and codes should never be billed to gain higher reimbursement

Just because a code is a ‘covered expense” doesn’t mean your carrier will issue a benefit for the service.

When an insurance carrier advises a patient to have their dentist re-submit with a different code, it may undermine the credibility of the dental team.  Be careful with this…misrepresentation on a claim form is not fun and games.  If your records are not consistent with the code you submitted, there may be consequences.


Your staff is in a no-win situation.  They have an upset patient who feels the claim wasn’t submitted properly.  They want you to “change the code” so they can get their benefits….you want to accommodate them, but it’s not the right thing to and the consequences are grave. What do you do?

Well, finally I have some information you may find helpful.  There is a website designed specifically to educate patients about the dental industry, how insurance works, what to expect and everything in-between.  It’s called TOOTH TRUTH FOR YOU. Click here to access the website.   Have them (as my mom would say) go the “the GOOGLE” and find the site.  I think you will find it refreshing.  I think it will lighten the burden to educate patients about how dental benefits works.

Finally, if you find yourself in this situation, where the patient is asking you to do something perhaps unethical, unlawful or just plain wrong because “their insurance carrier told them”….then take a deep breath, respectfully explain that it is likely not going to happen, refer them to the website and STAND YOUR GROUND!