April 15, 2019

To keep health care costs down, carriers are ramping up programs to detect, prevent and correct fraud, waste and abuse.
​
They implement programs to facilitate early detection through Utilization Review and data analysis.  Your office may have received some correspondence outlining where your practice stands compared to your peers.  You might even have completed an annual “mandatory training- attestation”.

We are in an environment where you need to be even more defensive than in the past and your documentation needs to be supportive of the codes you submit.

Something as simple as restorative codes could cost you (both monetarily and discipline wise) if your documentation doesn’t support the codes you are submitting.  I am seeing an increase in audits focusing on restorative procedures and although our dentists are diligent about recording tooth number, surface, material and shade, their chart notes don’t typically reflect why the restoration is needed.  The WHY is extremely important.  That is your diagnosis.  Without that, you open the doors for a dental carrier to recover benefits.

Let’s start with a simple example:  sealants versus composites.  What distinguishes a sealant or resin restoration placed in the pit and fissure area (sealant D1351) from a preventive resin restoration (D1352)?

Back in January 2011, the CDT Code was revised to enable separate reporting of these very distinctly different procedures.  By definition, the application of an unfilled resin or glass ionomer cement limited to the enamel surface is a sealant procedure and should be documented with code D1351.

If an unfilled resin or glass ionomer cement is applied to an area of an active cavitated lesion AND does not extend into the dentin, the procedure should be documented as a preventive resin restoration D1352.

Should the lesion extend into the dentin, the appropriate documentation code for a one surface composite would be D 2391.

Seems simple but if your patient chart notes don’t reflect WHY you placed the restoration and you are the lucky recipient of a “quality assessment” inquiry, you may be vulnerable and required to return any benefits for services that were rendered based on your lack of documentation.

Afterall, how do you defend yourself if your clinical notes don’t reflect caries and the buccal pit or lingual grove won’t demonstrate active caries radiographically?  Here is what you need to do!

There are specific diagnostic codes to document WHY you provide restorations.  Some examples are:

• K02.5            Dental caries on pit and fissure surface

• K02.51          Dental caries on pit and fissure surface limited to enamel

• K02.52          Dental caries on pit and fissure surface penetrating into dentin

• K02.53          Dental caries on pit and fissure surface penetrating into pulp

• K02.6            Dental caries on smooth surface

• K02.61          Dental caries on smooth surface limited to enamel

  White spot lesions (initial caries) on smooth surface of tooth

• K02.62          Dental caries on smooth surface penetrating into dentin

• K02.63          Dental caries on smooth surface penetrating into pulp

• K02.7             Dental root caries

• K02.9             Dental caries, unspecified

Make yourself a little handy dandy cheat sheet and have staff document WHY you are having the patient back for restorations based on the location of the caries and surface….because we all know these lesions do not show up radiographically.

• Dr. Joan's Coding Changes
• Coding for the Physicians of the Oral Cavity