Teresa Duncan, MS, FADIA, FAADOM is an international speaker who focuses on revenue, dental insurance & management issues. She is a Fellow of the American Association of Dental Office Managers. Her memberships include the Association of Certified Fraud Examiners, National Speakers Association and the Academy of Dental Management Consultants. She has been named one of the Top 25 Women in Dentistry by Dental Products Report. Teresa received her Master’s Degree in Healthcare Management.

Teresa Duncan, MS, FADIA, FAADOM

	Dental office websites often have financial sections that state, “You are responsible for knowing your insurance benefits, but we will help you file claims” or, “We’re happy to help you with your claims, but you are responsible for knowing your plan details.”

When these were written, they were no doubt intended in a friendly but firm way, but in our insurance-dominated landscape, it could easily be perceived as a red flag to the patient. What the patient really needs to read is “we’re here to help you with your benefits.”

How did we get from insisting that patients know their plans to becoming mini-insurance databases? Simple: The market has pushed us in that direction. 

 report 78 percent* of the plans sold are PPO plans. Let’s put it another way-individual and group purchasers of plans select plans that offer a preferred provider network in an effort to reduce expenses. These networks are swelling with providers now-a very different scenario from 10 or even five years ago.

Free on-demand webinar: Understanding medical billing and its relationship with 3D

This has created an opportunity for offices that are willing to take on the burden of discovering and tracking patient benefits. Is your insurance administrator collecting new patient benefit information on the new patient call? I hope so-if you wait to collect the information, you and the patient may be surprised at how the plan works in your office. Patients have already been primed by medical offices to hand over their insurance information rather robotically. Dental offices should also be collecting it but with much more of a customer service bent.

The patient relies on us to help decipher his or her benefits. Is that fair to the dental office? Definitely not. But is it the new business reality? Absolutely. Let’s look at it from a different perspective. Let’s say you are scheduled to have an inpatient surgery on your foot. Your surgeon’s office will likely preauthorize the procedure for you. But what would you do if the office asked you to find out what the surgery would cost and if there are any plan exclusions? Is there a limit to how much anesthesia you can have? What hospital can they use? What material can they use during the surgery? Is there a missing toe clause? You get the idea!

Related reading: Why insurance coordinators need to be flexible in today's dental world

*Source: 2014 NADP/DDPA Joint Dental Benefits Report on Enrollment  

Most of us wouldn’t know the first question to ask or even what department of the insurance company to call. We look to the surgeon’s administrator to know his or her way around the insurance maze. It’s a stretch to expect our patients to know enough to ask about alternate benefits such as amalgam-priced payments for composite fillings or partial denture payments for implant placements. For laughs, you could ask your neighbor to read that sentence and explain it back to you. It’s a rare patient that could do this. Frequency limitations for bitewings and crown placements regularly confuse providers, so it’s an easy assumption that patients wouldn’t even think to ask about it. The only time a patient is aware of a frequency limitation is because they have run into it at another office and ended up with unexpected out-of-pocket expense.

Related reading: Top 5 things you need to know about dental fees

This absolutely adds work to your already-stressed administrative team, but here’s what I tell my audiences: If you’re not helping them with their insurance, they’ll find an office that will. That’s hard to hear for a healthcare provider. We’re supposed to be blessed with the sanctity of the patient-doctor relationship. Ask your medical colleagues how well that relationship is working for them. American physicians’ private practice is highly influenced by the benefits market. I’m not suggesting we let insurance drive our decisions regarding patient care but that we realize how important it is to the patient that his or her benefits are understood.

I want your office to be the one that tells patients they’ll help with the language. Think of your team as translators of a foreign language for your patients. In essence, their dental benefits read like Latin to them. Your administrators are similar to a dental Rosetta Stone-provide your patients with the translation and a smile along with an offer to help rather than an admonishment that they should know their benefits.   

Teresa Duncan, MS, FADIA, FAADOM, is an international speaker who focuses on revenue, dental insurance and management issues. She is a fellow of the 

American Association of Dental Office Managers

the Academy of Dental Management Consultants

. She was recently named by DPR as one of the 

. Teresa received her master’s degree in health care management.

Video: What does the future hold for dental insurance?

Articles

 Dental office websites often have financial sections that state, “You are responsible for knowing your insurance benefits, but we will help you file claims” or, “We’re happy to help you with your claims, but you are responsible for knowing your plan details.”

The myth that patients should know their benefits

	Flexibility is the name of the game in today’s 

 world. Administrative roles have shifted greatly in recent years to include the growing, evolving role of insurance in the dental office.

My classes are attended by both newer and more veteran team members – both groups equally confused by the changing 

rules of thumb." The most dangerous phrases uttered in the administrative area are assumptive ones made out of habit, such as "insurance policies always cover…" or "your deductible won’t apply to your cleaning."

Offices (both participating and non-participating) feel increasing pressure to know a patient’s benefit plan inside and out. Is it unreasonable? Yes, absolutely. But is it expected? Yes, absolutely. And this is where reality meets theory. If I could wave a magic wand, I’d love for all offices to be able to estimate co-payments accurately and quickly. We can do one or the other, but, often, both are hard to find in one total package. The industry is moving in that direction, but, for most offices, the reality is full of long hold times, websites and faxes with less-than-complete information and patients who are clueless about how their benefits work.

Today’s insurance coordinators benefit from on-the-job training every day – because plans change just that quickly. What was once an assumption (i.e. all radiographs paid at the preventive percentage) can prove to be a costly mistake when communicating with patients. The main insurance coordinator in the office is typically an administrative person who expressed an interest in handling patient benefits. Ten years ago, this person could also pull double duty as receptionist or office manager. As benefit plans and networks become more complex, it becomes very plain that insurance management has become its own position. To ask a full-time receptionist to "just add these couple tasks" to his or her day is a recipe for burnout.

However, in many offices, the doctor or manager does not want to hire a full-time coordinator because this position is seen as a non-revenue-producing position. Many owners simply have no idea how much time is involved in managing this vital system. The typical day involves the following tasks for an insurance coordinator:

		Verifying eligibility for the next two days’ worth of patients

		Obtaining benefits for plans not entered into the practice management system

		Filing claims as procedures are posted (claims should be sent daily)

		Gathering information for narratives required for certain procedures

		Processing incoming insurance checks and sending statements to patients with residual balances (this includes paper checks and/or logging into the insurance companies’ web portals)

		Appealing claim denials or answering requests for more information

		Reviewing claim submission reports from the clearinghouse

		Reviewing treatment plans slated for presentation to ensure benefit estimations are accurate

		Answering patient phone inquiries regarding balances and benefits

Video: How to save time on dental insurance verifications

In addition to these daily tasks, there are other duties that need to be completed at regular intervals. These tasks can be bi-monthly or monthly depending on your volume:

		Running regular reports to track aging claims and pre-treatment estimates

		Calling to check on the status of unpaid claims

		Running a report to identify procedures not claimed

There are also reports that should be run quarterly and yearly that show how much production is tied to your carriers, but these are often performed by either the insurance coordinator or the office manager. Don’t forget about tracking when you can 

 and remembering re-credentialing deadlines. When I meet with seminar attendees I often hear that dealing with insurance is the most aggravating and least-liked task in the office. As a result, it is often the last system addressed, when, in reality, it should be handled efficiently on a daily basis.

Almost all offices I talk with could use a full-time insurance coordinator; however, there is great reluctance to assign one person to handle the insurance process. Don’t think of it as a cost center of your office. You stand to lose more revenue due to patient dissatisfaction, inaccurate co-payments and higher accounts receivables if you don’t streamline this system. A well trained and knowledgeable insurance coordinator can save your practice from losing revenue. With today’s tight dental office margins, it is a position you can’t afford to do without.

Related reading: 5 facts you should know about dental insurance coverage

 Flexibility is the name of the game in today’s dental insurance world. Administrative roles have shifted greatly in recent years to include the growing, evolving role of insurance in the dental office.

Why insurance coordinators need to be flexible in today's dental world

The Code on Dental Procedures and Nomenclature (CDT) is generally thought to be used only for efficient processing of dental claims. This is true yet incomplete. Another purpose for CDT is to populate Electronic Health Records (EHR). This second purpose saw more light in the 2014 discussion of the Code Maintenance Committee (CMC) and changes were made for CDT 2015.

The existence of a code does not mean a patient has coverage under a policy. Yet without a code, no coverage could be offered. Part of the Affordable Care Act is aimed at improving the quality, efficiency, and overall value of health care. Reimbursements will be tied to outcomes in the future. Having a code provides us with the opportunity to measure outcome data.

Revised implant codes section with 8 new codes, 4 deleted codes and 10+ revised codes

New codes for post-operative visits, sealant repair, evaluation for deep sedation or general anesthesia, and missed appointments

New codes were added to the diagnostic section for the re-evaluation of post-operative office visit and 3D photographic images. The added evaluation code D0171 that is meant to be used as for post-operative visits. The code will likely be subject to the evaluation frequency limitations.

In the Preventive section one code was added for sealant repair. Although the sealant repair code is helpful to accurately describe treatment, it will likely not be reimbursed as most sealants have a per tooth frequency limitation. Of greater interest is the revision of D1208 topical fluoride code to add the words-“excluding varnish.” Previously fluoride varnish could be submitted under either D1208 or D1206 though it is the role of the dental practice to use the most accurate code available. This change no longer gives the practice a choice.

It was once again submitted to the committee to add codes for different levels of prophylaxis. Once again, the committee decided this was not necessary. Similarly, the committee continues to vote “no” for a variety of laser-assisted periodontal therapy submissions. The given rationale is that since lasers are used in conjunction with other procedures, they could not identify how the submissions were different from procedures reported under current codes. Resubmissions to the committee include must 

 when the original change request form was prepared.

Restorative (D2000-D2999), Endodontics (D3000-D3999) and Periodontics (D4000-D4999)

There were no new codes added for the Restorative, Endodontics and Periodontics sections. There were minor revisions in each section.

Implants (D6000-D6199) and Fixed Prosthodontics (D6200-D6999)

The greatest number of changes was in the D6000-D6199 Implant section with 27 revised, eight added, and four codes deleted. Practices submitting from this section should pay attention to the changes (see Box 2).

Removable and fixed implant or abutment-supported dentures now have codes that indicate either maxillary or mandibular arch. The previous code only indicated that an arch was involved not which one. The new codes also delineate the arch’s condition. Offices will need to know the condition of the indicated arch when selecting the proper code.

Maryland bridges that utilize resin-bonded retainers now have an appropriate code: D6549. Previously you could designate cast metal or porcelain retainers and use D6999 to indicate a resin retainer. The new code solves this problem.


Offices that administer sedation now have a code for evaluation prior to the procedure D

9219 evaluation for deep sedation or general anesthesia

. This code takes into account that a provider other than the treating dentist may provide the anesthesia or sedation.

Adjunctive General Services (D9000-D9999)

Though there is no specific section for administrative code, two new codes were added to the Adjunctive Section for 

 after an extensive, robust discussion of the committee. This included a discussion of the need to add a new section for administration codes. These codes are needed for the requirements for administration in some states Medicaid. Some committee members questioned the need for these codes. Other members felt these measurements are important for continuity of care and electronic health records (EHR) coming forward.

As mentioned in the beginning, CDT is used to populate the electronic health record. EHR as well as the Affordable Care Act is moving our healthcare system toward more structured data gathering and evaluation. A standard EHR and interoperable national health information infrastructure requires the use of uniform health information standards, including a common language. Data must be collected and maintained in a standardized format using uniform definitions in order to link data within an EHR system or share health information with other systems. The lack of standards has been a key barrier to electronic connectivity in healthcare. Together, standard clinical terminologies and classifications represent a common medical language, allowing clinical data to be effectively utilized and shared among EHR systems. Neither a clinical terminology nor a classification can, by itself, serve all of the purposes for which health information is currently used or will be used in the future. CDT is one form of structured data.

“If coding is the same for everyone, or you think you already know the codes, you are not doing it right. To do it right, you must think and understand.”
-- Patti DiGangi and Christine Taxin

DentalCodeology: CDT 2015 shifts and dental coding tips every practice should know

	Author Robin Hobb wrote “One must plan for the future and anticipate the future without fearing the future.” At the recent 

 a few trends emerged that help us to plan for the shifting dental benefit landscape.

Related reading: Why are some insurance companies excluding dental care? 

Dental industry watchers have always taken note of changes in medical plan design and now must include observations on the impact of 

 – kept us repeating the words “we don’t know.” This is in response to questions that we all have: what will dental benefits look like in ten years? Will the ACA be repealed? Will employers move away from stand-alone dental plans? The response to all of these and more is quite frankly “we don’t know.” Ms. Pearson did a great job discussing the ways employers will seek to keep dental plan costs low.

Other themes included network improvement and analytics. The use of narrow networks has taken hold on the medical side of health care and we are starting to see their increased usage in dentistry. Narrow networks refer to the utilization of smaller panels of providers in an effort to reduce cost. Many of these plans that utilize narrow networks do not provide benefits outside of the network providers.

Trending article: Antidepressant drug linked to dental implant failure

Data collection and analysis companies were well represented on the exhibit floor. Companies seek to not only control costs but to identify providers that abuse coding practices. The ability to identify outlier patterns is helped by the increased communication of patient data via 

EHR, as well as the Affordable Care Act, is moving our healthcare system toward more structured data. A standard EHR and interoperable national health information infrastructure requires the use of uniform health information standards, including a common language. Data must be collected and maintained in a standardized format, using uniform definitions, in order to link data within an EHR system or share health information among systems.

The conference concluded with a panel discussion on the future of dental benefits. The outlook was cautiously optimistic that employers would continue to provide dental benefits to our patients. The challenge will be to keep these benefits affordable for both the purchaser and the employee.          

5 facts you should know about dental insurance coverage

Editor's note: We caught up with Teresa Duncan at the ADA Annual Session in San Antonio and asked her about what was coming in insurance and what dental professionals needed to know. See our exclusive video interview below...

, is a clinician, speaker, author and coach. She is an ADA Evidence Based Champion and holds a publishing license with the American Dental Association for Current Dental Terminology. She is the author of the DentalCodeology series of mini-books. She was awarded the 2014 Sunstar Award of Distinction, 2014 CE Leaders Recognition and 2013 Sonicare Mentor of Distinction.

, is an international speaker who focuses on revenue & management issues. She is a Fellow of the American Assn of Dental Office Managers. Her memberships include the American Academy of Dental Consultants, National Speakers Association and the Academy of Dental Management Consultants. She was recently named one of the 

 Teresa received her Master’s Degree in Healthcare Management. 

 Author Robin Hobb wrote “One must plan for the future and anticipate the future without fearing the future.” At the recent 2014 Converge Session of the National Association of Dental Plans a few trends emerged that help us to plan for the shifting dental benefit landscape.

What does the future hold for dental insurance? [VIDEO]

We worked with large scheduling books and wielded mighty pencils and a formidable stack of sticky notes. Tear-away pads of routing slips and referral pads were always within reach. Our copy machine was humming and stacks of copy paper were always kept in stock. The outside of charts were full of numbers as that’s where the balances were recorded.

If you think reading account ledgers and estimating copayments with your 

 can be problematic, have I got a scenario for you! The old way of calculating copayments was to pull out the calculator, do the quick button work and then flip the calculator around.

That was how you told the patient how much was due. If you had to work with a PPO plan then you were pulling out fee schedules, and fingers worked at lightning speed to come up with the correct amounts. This was before financial arrangements were routine, and payment promises were recorded on sticky notes that may or may not stay with the chart.  

Fast forward to 2012 and you can see that we’ve come a long way. Paperless technology has freed up so much time for managers to truly manage-not just push data around on various bits of paper. Our job now entails analyzing this data and helping to make strategic decisions with the doctor.

Our computers calculate our copayments and print out necessary truth-in-lending forms. Rather than photocopying periodontal readings with markings that look like hieroglyphics we now hand a color chart and informative treatment plans to the patient. We not only are tech savvy but the patients feel and see it for themselves.


	Stored data is now easily retrievable and sortable, making it possible to see trends that impact our practice. The secret to good management is to anticipate the factors that can cause the most disruption to our practice.

The only way to do this is to pay attention to that data-often. The challenge with paperless technology is the same challenge with loose paper: is the data correct?

Managers should be checking this information on a routine basis. Have referrals been entered correctly so we can track our marketing return on investments? Have our claims left our office with correct data so we don’t have to wait to find out the claim was rejected weeks ago? Is the medical information for each patient current and up-to-date so we aren’t taking chances with sedation?

Data that’s easy to read and easy to access is a manager’s dream-all these checks and balances can happen much easier now with all the various reports that are a click away.


	We often hear from office managers who manage multi-location or group practices. The need for centralized information is so important to this population. Before chartless technology many of these offices would have to be extra vigilant to make sure the right chart was at the right office at the right time.

The team has to be prepared in case Mrs. Smith decides to go to the West Side location but her chart “lives” in the East Side office. The typical solution was to have Rachel the Runner speed through traffic between the offices with chart in hand. However there were times when the mistake wasn’t discovered until the patient was actually in the chair. You could easily visualize the miscommunication and schedule delays that occurred as a result of a patient wishing to visit a different location.


	So much change and so much progress-have we even reached a peak? No-we’re still on the march uphill. The mandate for electronic health records (EHR) is a few years away and the possibility of dental diagnostic codes will renew an interest in technology solutions.

Many offices have taken the step toward not only becoming just chartless but truly paperless. That means no photocopies of ID cards and referral forms sitting in a thinner file. The hum of scanners will replace the old copy machine and rightly so. Let our computer storage work for us instead of making room for physical storage. Take your time, do the research and implement with a plan.

Remember how we should anticipate disruption. At one time transitioning to a paperless office was considered the ultimate disruption. It will be the most positive disruption you could ever manage.

Imagine the administrative area of a dental office of 20 years ago.

Paperless technology frees up the dental office manager's time

Creating codes to embrace new technologies, materials, and procedures can lead to earlier arrest and prevention of oral disease and positively influence systemic health. For the past decade, the CDT codes were updated every two years. To facilitate a fast-moving world, CDT is now updated every year. The existence of code does not mean a patient has coverage under a policy, yet without a code, no coverage could be offered.

Part of the Affordable Care Act is aimed at improving the quality, efficiency, and overall value of health care. Reimbursements will be tied to outcomes in the future. Having a code gives opportunity to measure outcome data. CDT 2014 has changes in all 12 sections showing a shift with the addition of codes for regenerative procedures and stages of care.

Three new caries risk assessments and documentation codes were added to CDT 2014. The description for all three codes: “Using recognized assessment tools.” Because the code contains the word 

writing the dental/medical necessity in this case the method of determining caries risk is needed.

These caries risk codes ARE NOT codes for specific treatments; they are to determine risk. They should be submitted 

 other codes. The new codes are: D0601 caries risk assessment and documentation, with a finding of low risk, D0602 moderate risk and D0603 high risk. Reimbursement for these codes should not be expected since they do not describe actual provided treatment.

Diagnostic Imaging (formerly Radiographs) section contained the greatest number of changes in CDT 2013 particularly adding numerous codes for cone beam computed tomography (CBCT). This pattern was refined by adding more description to the codes plus adding new codes.  The new codes enable clinicians to describe the process of image capture, reconstruction and interpretation with more versatility than was previously available. CBCT images can assist in making a definitive diagnosis, help with treatment planning and follow-up care, and result in precise and favorable outcomes.

There is always a code. It doesn’t sound right to many, but it is true. All 12 sections of CDT contained a 

 code D_999 unspecified __ procedure, by report as the last code in each section except in the Preventive Section. The new code D1999 unspecified preventive procedure, by report was added to CDT 2014.

Atraumatic/alternative restorative treatment (ART) is a procedure involving the removal of soft, demineralized tooth tissue using hand instrument alone, followed by restoration of the tooth with an adhesive restorative material, routinely glass ionomer. ART is endorsed by the World Health Organization. Interim therapeutic restoration (ITR) more accurately reflects the procedure as practiced in the U.S. creating the need for the new code D2941 interim therapeutic restoration primary dentition.

Crown buildup code D2950 was modified to express that the addition of coronal structure should not be used to eliminate undercuts, box cuts or concave irregularity. The new code D2949 more accurately describes the addition of foundational structure for the purposes listed above.

This section now has a subcategory to describe pulpal regeneration procedures. For offices that only had pulpal exposure, limited pulpal regeneration and apexification codes to choose from this new subcategory offers much more descriptive codes. This subcategory also includes descriptors that include bone grafting and biologic material so be careful to not confuse them with similar existing codes in the periodontal category.

Gingival irrigation is an important part periodontal therapy protocol in many offices yet there has not been a specific code. D4999 unspecified periodontal procedure was submitted more than 500,000 times in 2012. There has not been support of the code in the past by some code committee members because they question the clinical efficacy of one-time irrigation. Like many procedures in clinical practice, there is a gap between what science supports and what is routinely performed.

The National Dental-Practice Based Research Network

 is seeking close these gaps and to enroll more practitioners to contribute to their scientific endeavors. The new code is D4921 gingival irrigation per quadrant is now available for practices using this therapy. This will help many offices who have been irrigating with chlorhexidine or another medicament but have never had a code to adequately describe the procedure.

Codes are not product-specific. Some procedures do not seem to have a code that accurately fits. An example of gaining an accurate code is for the minimally invasive procedure using Perio Protect trays. The Perio Protect Method tray is a prescription medical device that places medication in the sulcus or periodontal pocket.

It is not co-packaged with any medication. It is simply an effective tool for subgingival delivery to address biofilm infections, inflammation, root caries or recession-induced sensitivity. The trays have customized seals and extensions fabricated along the interior periphery to prevent medication from leaking and provide positive pressure to direct medication deep into the sulcus and periodontal pocket. Perio Protect Method trays are classified as prescription medical devices, they require a doctor’s script and must be fabricated in a dental laboratory registered with FDA and trained by Perio Protect LLC.

The only code previously available for the procedure was D5991 topical medicament carrier which did not accurately describe the procedure. The new code is D5994 periodontal medicament carrier with peripheral seal laboratory processed.

Offices have struggled for years with how to code mini-implants and finally we have a code that is appropriate. Previously mini-implants that were permanently placed were coded with D6010. However the price for a mini-implant is usually lower than the cost of a traditional implant. This was hard for offices to track so the addition of code D6013 to denote permanent placement of a mini-implant is very helpful. Don’t forget that any implant placed temporarily regardless of size  is to be coded with D6012.

Offices who uncover implants after they have been placed at another office finally have a code to describe this procedure. Code D6011 describes the surgical access to an implant for placement of a healing cap or to prepare for abutment placement. Offices that were providing this service had no accurate code prior to 2014.

It is important to understand the revision of code D6080 implant maintenance procedures when prostheses are removed and reinserted, including cleansing of prostheses and abutments. This code is NOT for routine prophylactic care of implant supported prostheses. It is for very specific complex situations. In order to use this code, the prostheses MUST be removed.  This is an important distinction as many offices previously used the code when several implants were present along with natural dentition.

The new sales tax code D9985 will not be a reimbursable code. However several states require dentists to charge sales tax on sales of items such as toothpaste, toothbrushes and mouthwashes. Check with your accountant to see if you are in one of the states that requires the reporting of such a tax.

Staying current on coding is a continuous process. 

 plans to release and modify new codes every year and it will be up to each office to remain current. The use of outdated CDT codes on your claim forms can delay payment or even cause the denial of a claim.