2010 Fee and Insurance Code Update

Tom M. Limoli Jr.

January 1st of 2011 will bring about some rather unique as well as potentially troublesome and challenging issues.
For the Limoli family, it will be the year that I turn 50 years old. My stepdaughter, Brooke, will no longer be considered a preteen; she will soon be dating and driving. My father, Dr. Tom Limoli, Sr, will have been gone 5 years, while my wife Penny and I are just beginning our journey together. Dad’s memories and life lessons will continue to strengthen, while lives together bring about new joys and challenges that make us all more ready for tomorrow. Most of this change cannot in any way be avoided, or controlled, as it must simply be appropriately managed.

By direction of the American Dental Association (ADA), the comprehensive list of ADA insurance codes and fees are no longer allowed to be posted or published by anyone other than the ADA.

And speaking of challenges, the dental profession will be faced with many new definitions and changes to the codes on dental procedure and nomenclature. Let’s take a look into the future and briefly see what is in store for 2011.


REDEFINED
Diagnostic

Unless you own or are employed by a pathology laboratory, the redefinition of D0486, once again, is going to have absolutely no impact on your day-to-day life.

Restorative
What was a sedative filling is still D2940 but it is now called a “protective restoration.” The descriptor is somewhat improved but it now contradicts D9110 while at the same time specifying its previous inappropriate usage for closing an endodontic access hole.

Endodontics
D3351 and D3352 apexification/recalcification codes have been clarified to more specifically address the interrelationship with new code D3354 pulpal regeneration so as to not add confusion concerning appropriate utilization. More on code D3354 will come later.

Periodontics
In summary, D4263 and D4264 bone replacement grafts, D4266 and D4267 guided tissue regeneration, and D4320 and D4321 provisional splinting all have grammatical as well as technique-sensitive corrections to the descriptors.

Implant Services
Existing code D6055 implant connecting bar can now be used for both implant or abutment supported bars, while D6950 precision attachment specifies that it is identified separately from the prosthetic.

Oral and Maxillofacial Surgery
Thankfully, D7210 surgical extraction still requires removal of bone and/or sectioning of the tooth but now the mucoperiosteal flap is not longer required, while D7953 bone replacement for ridge preservation and D7960 frenulectomy, frenectomy, and frenotomy have well needed updated descriptors.

Adjunctive
Of confusion is the redefinition of local anesthesia D9215 indicating its potential submission on benefit claims, with both operative as well as surgical procedures. The futures of the electronic health record notwithstanding, how many operative and surgical procedures are you doing without at least local anesthesia? This has the administrative nightmare of CDT-2005 written all over it. Have we not learned from the past?
And now to top it all off, analgesia D9230 was redefined by simply reversing the order of the words in order to pacify Sister Mary, my fourth grade English Composition teacher, while D9420 now includes visits to ambulatory surgical centers as well as hospitals. What a relief…

NEW

Preventive
Preventive resin restorations in a permanent tooth will fall, or fail, under new code D1352. It does nothing more than simply identify when a sealant is still a sealant but can now be classified as being a “super sealant.” I will stand my ground and share with you today my personal observation that this ill intended and poorly designed CDT procedure code has the potential for health care fraud and inappropriate utilization abuse written all over it.

Endodontics
In the endodontic section, code D3354 will be used for regenerating the damaged pulp of a necrotic, as opposed to neurotic, immature permanent tooth.

Maxillofacial Prosthetics
Want to see an emotionally challenged and previously helpless/hopeless patient’s life change right before your eyes? Go back (and give back) to the art and science of dentistry by spending some time with the artisans we all know as the maxillofacial prosthodontist. New code D5992 will be for adjusting a prosthetic appliance identified in the “D5900” section of the code. Also at their disposal is will be D5993, which identifies the cleaning and maintenance of those same appliances found in the “D5900” section of the code. These codes are not intended to identify the simple adjusting and cleaning of traditional full or partial dentures.

Prosthodontics, Fixed
In the fixed partial denture section, codes D6254 and D6795 can be used for identifying interim bridges when not entirely part of routine prosthetic services. As with any interim appliance, its intention is strictly to maintain the patient while healing, resolution, and other procedures are completing.

Oral and Maxillofacial Surgery
New to the oral surgery section is D7251 for identifying the intentional removal of only a portion of a tooth so as to not create a neurovascular complication while D7295 is for identifying only the harvesting of bone when it is going to be used in an autogenous grafting procedure.

FEE DATA
For this year’s fee presentation we have simplified the information by dividing the data into “LOW,” “MEDIUM,” and “HIGH.” The “NATIONAL AVERAGE” and “NATIONAL RELATIVE VALUE” are listed for your convenience.
The sample fee data represents 100% of the 90th percentile, calculated by distribution, using actual fees charged from across the country within a fee-for-service dentistry model. These data do not represent benefit plan reimbursement tables or schedules. The data was created from submitted benefit claims as well as fee schedules submitted directly to our Web site (limoli.com) for analysis.
The last column represents the relative values created by Limoli & Associates. These are provided to assist each private practice dentist in realizing the interrelated values of various codes and fees.
Take care and please do not trap yourself by attempting to establish your office fee schedule based on what some third-party payer reimburses at 65% of the 85th percentile. And don’t establish your fees based on the dentist down the hall or across the street. Your fees should be based on your overhead, expenses, patient base and your individual level of professional expertise.

SUPPLEMENTAL READING/RESOURCES
Current Dental Terminology is available directly from the American Dental Association and the Dental Insurance and Reimbursement—Coding and Claim Submission Manual is available at the Web site limoli.com.


Mr. Limoli received his bachelor of science in Criminal Justice from Valdosta State University. Following his work with the US Treasury Department’s Federal Law Enforcement Training Center, Mr. Limoli has actively investigated fraudulent claims for the insurance industry, as well as numerous other third-party fiduciaries. He is a licensed private investigator and a member of the American Association of Dental Consultants, the National Speakers Association, the National Health Care Anti-Fraud Association, and the past president of the Academy of Dental Management Consultants. Mr. Limoli is the prevailing expert on proper coding and administration of dental insurance benefit claims. Mr. Limoli is the author of Dental Insurance and Reimbursement: Coding and Claim Submission and co-author of Fee-for-Service Dentistry With a Managed-Care Component. Questions can be directed to Tom at (800) 344-2633, e-mail This e-mail address is being protected from spambots. You need JavaScript enabled to view it , or visit the Web site limoli.com.

Disclosure: He serves as president of Limoli and Associates/Atlanta Dental Consultants, which is a company that for more than 25 years has assisted dental offices in streamlining the insurance reimbursement process.