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Thursday Troubleshooter: This office believes new code D4346 ‘won’t be covered anyway,’ so why bother?

Nov. 2, 2017
Should this dental practice blow off using code D4346 because they believe "it won't be covered anyway"? See how this dental coding expert advises them.

Nearly everyone has problems and concerns on the job, and sometimes you're just too close to a situation to solve something yourself. Share your concerns with Team Troubleshooter, and the experts will examine the issues and provide guidance. Send questions to [email protected].


QUESTION:
I am a hygiene educator. One of my recent graduates said that an office where she’s employed will not use the D4346 code because they believe it probably won't be covered anyway. What would be your response to her?

ANSWER FROM PATTI DIGANGI, coauthor of the “DentalCodeology” series of books:
That’s a great question. I’ll share the answer from my book DentalCodeology: A Gingivitis Code Finally!

Some practices seem to think, “The insurance probably won’t pay certain codes anyway, so why bother to use them?” This assumption is a mistake. Dental practices are required to use the most accurate code to describe the care rendered. To use a different code for the purpose of payment could be considered dental fraud.

Dr. Charles Blair said, “Dental fraud is any crime where an individual receives insurance money for filing a false claim, inflating a claim, or billing for services not rendered. Fraud is sometimes called the ‘hidden’ crime because we are all victims without even noticing it.”

For example, rather than using the new CDT 2017 code D4346, the office chooses to 1) remap (formerly called under-coding) as a prophylaxis procedure, or 2) remap (formerly called over-coding) as a scaling and root planing procedure or gross debridement.

Since an accurate codenow exists, it should be used. Avoiding fraud and adopting a policy of proper coding is a process for the entire team. Without knowledge of the codes and how they’re being applied, there’s the likelihood of insurance fraud being committed. Even if the practice doesn’t “get caught,” this is where ethics come in. Not getting caught doing wrong or committing fraud doesn’t mean it didn’t happened.

Bottom line, because it bears worth repeating: If an accurate code exists, which it now does, it must be used.

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