Coding 101

April 10, 2002
Understanding the Ins and Outs of Insurance Claims Review

On the list of things that cause dentists headaches, dealing with insurance holds a primary position. Keeping track of coding changes and transaction regulations, understanding the ins and outs of each company's specific provisions, and chasing seemingly stagnant reimbursements steal precious time from patient care and can fray the nerves of the most balanced general practitioner. Academy of General Dentistry (AGD) membership surveys consistently show that dealing with insurance companies leads the list of dentists' gripes, according to an article in the April issue of AGD Impact, the monthly newsmagazine of the AGD.

Third-party payment mechanisms are the conduit for $60 billion into dental offices, but insurance companies' increasing reliance on post-procedure utilization review seems to have resulted in more denied claims. Insurance companies say the reviews are necessary to battle fraud and abuse. Commonly quoted figures from a California Medicaid study say as many as 10 percent to 13 percent of all medical and dental insurance claims are fraudulent, but even dental insurance consultants admit the number of dentists committing fraud and abuse is as small as half of 1 percent.

Beyond the numbers of fraudulent claims, dental insurance consultants claim dentists take liberties in coding. Consultants say they see too many dentists billing simple procedures as more complicated (and more costly) treatments; unbundling procedures and utilizing other "creative coding" techniques.

And dentists claim abuses by the insurance companies. Recently, the AGD Council on Dental Care has collected evidence that suggests claims coding manipulation and misuse of CDT descriptors by certain third-party payers, and has followed up with correspondence to the involved insurers.

The benefits landscape is changing, and dentists are searching for guidance on how to code and submit claims properly. But a lot of questionable information and advice on coding is being touted on the CDE circuit, according to dentists and consultants.

The April issue of AGD Impact examines coding issues, talking with dental leaders and insurance consultants with the largest companies to find out what dentists can do-and what they should avoid-to increase their chances for predictable claims approval in this shifting benefits market. The full article, "Coding 101" is available on the Academy of General Dentistry Web site,