Question

Q: Who must sign the assignment of benefits? Is it necessary to have the insurance subscriber sign
an assignment of benefits and release of dental information form if the spouse and children are patients, but the subscriber is not?

A: Most dental practices simply rely on the patient’s signature. A spouse is able to sign the assignment of
benefits for herself and for dependent children, as if they are the insured. However, it is important to obtain
and keep a copy of the photo ID (i.e., driver’s license) of the spouse/patient to verify the identity of the
individual using the insurance card. There have been cases where a patient has “borrowed” an insured’s
identity and insurance card in order to use the insured’s benefits. In several cases the provider has been
required to reimburse the payer for payments made for the “imposter’s care” because the practice failed to
properly verify the identity of the patient.

A subscriber does not have to sign a “standing” authorization to release patient information for a spouse
except in cases where the subscriber has power of attorney for the patient, or if the patient is a minor. Under HIPAA, once a patient signs an acknowledgment of the provider’s Notice of Privacy Practice, unless the patient has paid for services in full at the time of treatment and requested in writing that the provider not bill the dental plan, the provider does not need a separate authorization to release patient information to the payer. This is allowed as an integral part of the treatment, payment, and healthcare operations.

Q: What place of service code and treatment location address should be reported on the claim
form when a patient is treated in the emergency room at a hospital?

A: The place of service should be entered in Box 38 of the 2019 ADA Dental Claim Form. The place of service code for a hospital emergency room visit is 23. The treatment location should reflect the address where the treatment was actually performed. The billing entity (office) information remains the same.

Q: Why is it important to include the address of the place of service on the claim form?

A: If a dental practice has multiple locations and these locations share the same practice name and billing entity, then the address of the place of service must be reported on the claim form if different than the address of the billing entity. The ZIP code of the place of service often determines the fee level of the benefit received. If a hospital case, then the hospital address is listed as the place of service, etc.

Q: Can I bill for a crown that the lab delivered, but was never seated?

A: Yes, you can bill the payer for the crown, but you will need to provide an explanation as to why the crown was not seated. In addition, send a brief narrative and supporting documentation as evidence of medical necessity.

Include a narrative explaining the clinical necessity for the crown and, at a minimum send diagnostic preoperative radiographs and pre-operative photographic images, if available. Send a copy of the laboratory prescription and bill for the crown. The date of service is the date the tooth was prepared for the crown (prep date).

If the crown was not seated because the patient failed to keep scheduled appointments to complete the
treatment, explain what was done to encourage the patient to follow through with treatment. Also include
a copy of any documentation of the failed or cancelled appointments. It is helpful to send a certified letter to
the patient and provide a copy of this letter for documentation.

The payer may reimburse the contracted amount or pay a prorated amount to compensate for the laboratory bill and chair time. However, some payers will pay nothing. The practice can report the full amount, explain the circumstances, and let the payer decide what is payable based on the terms of the plan document. The “incurred liability date” of the plan document often requires “delivery” (e.g., cementing or bonding the crown) for any payment. Most PPO contracts or the Payer’s Processing Policy Manual require that crowns be reported on the seat date, not the preparation date.

Q: Why do some payers not receive all of the narrative characters entered into the remarks section
of the electronic claim form?

A: When submitting an electronic claim, typically only 80 characters are guaranteed to make it through to the payer once the claim is processed by the clearing house. Your practice management software may allow you to enter more than 80 characters, but only 80 characters including punctuation are guaranteed to be received by the payer. If a lengthy narrative is required, submit it as an attachment to the electronic  claim.

Q: Our hygienist recently attended training on how to use the OralID®. Are we allowed to bill for this screening by the hygienist using D0431 (adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures) or is this code only reimbursable when the doctor performs the screening?

A: Yes, a hygienist can perform a preliminary screening using the OralID®. However, in order to report the
procedure for payment, the doctor must also review, examine, and provide a final determination of the
condition(s) observed and any associated diagnosis.

Q: Our practice has a new associate. When he joined our practice and was credentialed with one of our PPOs, they assigned a fee schedule lower than the practice owner’s previously contracted current fee schedule. When the new associate performs the periodic oral evaluation and the hygienist performs a prophylaxis and/or other hygiene services, may we submit a separate claim for the prophylaxis showing the practice owner as the treating doctor for the hygiene services, while submitting a claim for the periodic evaluation showing the associate as the treating doctor in order to be reimbursed at the owner’s higher fee schedule?

A: No, the doctor who actually performs the periodic oral evaluation including the review of radiographs is
thereby supervising the hygienist and should be reported as the treating doctor on the claim form for services performed by the hygienist and for the periodic oral evaluation.

Q: We routinely take 4 periapicals and 4 bitewing radiographs annually for all recare patients. Most payers remap radiographic images and pay the benefit for a complete series of radiographic images, which applies against the frequency limitation. As an out-of-network provider, can we continue this radiograph protocol, but report only 4 bitewings and charge the patient separately for the 4 periapicals, thus avoiding remapping to complete series of radiographic images?

A: First, having a standing protocol of this type, regardless of the medical necessity, is problematic. Radiographs should only be taken when ordered by the doctor based on medical necessity, and ADA/FDA guidelines. Secondly, always report what you do. If not, it is considered underbilling and is inappropriate.

Q: If treatment is performed on a tooth and more comprehensive treatment is needed on the same tooth at a later date, how is that communicated to the payer and how is it reported? (Example: A composite restoration is completed in good faith, then the tooth fractures and the doctor determines a crown is subsequently needed.)

A: When a composite restoration is performed and the tooth fractures later necessitating a crown, notify the insurance payer of the good faith effort. The payer may reconsider the payment made for the filling and
“take back” the amount previously paid for the filling from the subsequent crown reimbursement. Note: You
should not perform a core buildup and report it as a restoration or vice versa. A core buildup requires the full preparation of the tooth plus application of the core buildup material, and a temporary.

Q: Will dental offices be required to submit diagnoses codes for routine dental claims? We were under the impression that the only time the ICD-10-CM codes would affect us would be for medical claim submission for surgical extractions, accidents, sleep apnea, implants, etc.

A: Some state Medicaid and Affordable Care Act (ACA) plans with pediatric dental benefits embedded in the health plan currently require ICD-10-CM diagnoses codes for all dental claims. This trend is expected to continue among payers. In some cases a pharmacy may call for an ICD-10-CM diagnosis code.

Q: We are a Pediatric practice with an anesthesiologist in the office 1 day per week. The anesthesiologist is out-of-network with the doctor’s PPO plans. Can we submit all claims for anesthesia and treatment under the treating dentist name?

A: No. The doctor who provided the dental treatment should be listed as the treating doctor on the claim form. The claim for the anesthesia services should report the anesthesiologist’s name and Type 1 NPI as the treating doctor for the anesthesia services on a separate claim form.

The anesthesiologist should “rent” the space from the practice (at fair market value) and bill all fees directly
to the patient. It is not acceptable for the anesthesiologist to pay the practice a percentage of overall patient revenues. Paying a percentage of patient revenues is considered fee splitting, which is considered illegal and unethical. The specialist should pay a fixed, fair market rent per month, regardless of  production.

Another option is for the practice to bill the patient as the billing entity with the anesthesiologist as the
provider. The practice would then have more flexibility with payment options for the associate and would then report the specialist’s income on either a 1099 (to their legal entity) or a W-2, if an employee. In this case, the pediatric practice’s Type 2 NPI is listed as the billing entity on the claim and the anesthesiologist’s Type 1 NPI is listed as the treating doctor. Payers always issue 1099s under the taxpayer Identification Number (TIN) for the billing entity, not the treating doctor’s Type 1 NPI.

Q: What is a clean claim?

A: A clean claim is one that is free of errors. All patient, subscriber, and provider demographic information must be accurate and match the payer’s files. The claim must include current procedure/diagnoses codes, utilize the correct claim form, and include all required information.

Q: When panorex and bitewing radiographs are taken on the same date of service, can we bill the panorex on a separate claim or on a different date to avoid the payer remapping the 2 procedures and paying an alternate benefit of a full mouth series (FMX)?

A: No, this is an inappropriate billing practice. While claims may be auto-adjudicated and both radiographs paid as separate procedures initially, this coding practice could be considered a scheme to increase reimbursement and may trigger an audit.

Q: When applying for a Type 2 NPI number, do I provide the legal practice entity name as listed on
my W9, or our DBA (“doing business as”) name?

A: When applying for a Type 2 NPI number which identifies the billing entity, apply using the legal entity name. There is also a place on the application to enter the DBA.