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QUESTION: We have many patients present at our office who have already used up their full-mouth x-ray (FMX) benefit at another dentist. For us to properly diagnose them and not miss anything and risk being held accountable, we need to take a full series of x-rays. Is there any legal liability with insurance when taking an FMX but only billing for the bitewings? We’re going the extra mile to obtain all of the necessary information for patients, but we’re billing the insurance company a lesser code based upon their frequency availability.
ANSWER FROM PATTI DiGANGI, founder of DentalCodeology:
Congratulations! Our patients are hungry for practices that will go out of their way to engage with them and give them the care they seek. At the same time, a practice cannot cross over ethical and legal lines with its help. Then you might accidently commit fraud. Fraud by accident or ignorance is still fraud. Yikes! you say. You’re just trying to help. So, what is the best way that you can help?
I’ll assume that your practice contacted the carrier about benefits, and that the discussion included available radiograph benefits. You were told that there was a recent FMX and that based on the patient’s policy, no further benefit was available.
My first question is why your practice is not able to get a copy of those images? You need the date and to see the quality of those images. If you can get those and they are not diagnostic, or the patient has changed significantly, then a new set might be needed.
We are not accustomed to documenting the reasons for the radiographs. There are no codes for simply taking them. Radiographs need to have a reason and a result documented. Radiographs need to be medically necessary, not calendar-based, based on risk, and individualized.
The ADA/FDA Guidelines on Radiographs offers many details regarding the why, how, how often, and more of taking radiographs. Box 35 Remarks of the ADA claim form is the place for information when the diagnosis may affect claim adjudication when a procedure may minimize the risks associated with the connection between a patient’s oral and systemic health conditions. For example, if a patient has high blood pressure or diabetes and shows signs of periodontal disease, these would be viable reasons for updating an FMX, especially if it had been taken more than a year earlier.
Life is dynamic and patients’ health changes all the time. The question must be looked at from the larger perspective of that individual’s health, not just a policy.
Let’s go back to your dilemma. Your excellent question is, is there any legal liability with insurance when taking an FMX but only billing out for the bitewings? From a documentation point of view, you are required to accurately document the treatment performed. If an FMX is taken, this needs to be documented.
Can you choose to only submit for payment for bitewings (BWX)? A practice can choose to charge whatever it wants. But how you ethically fill out the claim is not the same choice. Record FMX as the procedure performed. Then in the Box 35 Remarks of claim form report that an FMX was taken for (the specific reason), then add, “If no benefits for D0120, please consider D0274.” The carrier can then pay for the BWX based on what’s available under contract, and your office will have made an accurate, ethical claim.
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