Billing and Coding Canker Sores, a Common Oral Condition

Billing and Coding Canker Sores, a Common Oral Condition

One of the most common complaints of the mouth, canker sores are small, shallow lesions that develop on the soft tissues in the mouth or at the base of the gums. Also called aphthous ulcer or aphthous stomatitis, it may occur on the tongue and on the inside linings of the cheeks, lips and throat. In most cases, these sores appear white, gray or yellow in color, surrounded by red, inflamed soft tissue. Usually, very small in appearance (less than 1 mm), the sores may enlarge to ½ to 1-inch diameter, can be painful and often make eating and talking uncomfortable. Recurrent in nature, in most cases these sores will heal on their own, but will reappear in the same or new locations after a specific period of time. In severe cases, old ulcers may be healing while new ones may appear. It is estimated that around 20-30 percent of people have recurrent episodes. In most cases, canker sores are self-limiting, meaning they will go away (in a week or two) even without any specific treatment. Billing and coding for this dental condition can be challenging. Dentists or other specialists offering treatment for this mouth condition need to ensure that the medical billing and coding for the same is done appropriately on the medical claims. Relying on the services of an established dental billing company would be a practical solution for timely claim filing and correct reimbursement.

Canker sores affect about 20 percent of people in the United States. It is estimated that about 1 in 5 people gets canker sores regularly. Even though they can occur at any age, they are most likely to occur in younger adults and women (possibly because of hormonal differences in women).
Children as young as 2 years may develop canker sores, but they do not normally appear until adolescence.

Causes and Types of Canker Sores

The exact causes of canker sores are not known. Researchers suspect a combination of factors like viral infections, allergies, a family history of aphthous ulcers and nutritional deficiency may contribute to outbreaks. Other related factors include – a minor injury to your mouth (from dental work, overzealous brushing, sports mishaps or an accidental cheek bite), food sensitivities, hormonal problems and other vitamin and mineral deficiencies. Mouth sores can also occur due to certain conditions and diseases such as inflammatory bowel disease, celiac disease, faulty immune system and Behcet’s disease (a rare disorder that causes inflammation throughout the body, including the mouth).

There are several types of canker sores – simple, complex and herpetiform sores.

  • Simple canker sores – Also called minor sores, these are the most common types of mouth sores that occur in people aged 10-20 years. Small and oval in shape (with a red edge), these appear 3-4 times a year and heal without scarring in one or two weeks.
  • Complex canker sores – Less common in nature, these sores are larger, deeper and more painful than minor canker sores. Usually round in nature, with defined borders, these sores may have extremely irregular edges when very large. Complex sores can occur due to an underlying condition like a compromised immune system, Crohn’s disease, or vitamin deficiency and may take up to six weeks to heal, leaving extensive scarring.
  • Herpetiform canker sores – Caused by herpes virus infection, these sores are pinpoint in size with irregular edges and usually develop later in life. These sores in most cases, occur in clusters of 10-100 sores, but may merge into one large ulcer. It may heal without scarring within 1-2 weeks.

Signs and Symptoms

In most cases, canker sores are round or oval in shape with a white or yellow center and a red border. The sores as mentioned above may form inside the mouth – on or under the tongue, inside the cheeks or lips, at the base of the gums or on the soft palate. Patients may experience local pain or notice a tingling or burning sensation a day or two before the sores actually appear. Common symptoms seen in the mouth include –

  • A small white or yellow oval-shaped ulcer
  • A painful red area
  • A tingling sensation

In severe cases, other symptoms like swollen lymph nodes, fever and a feeling of sluggishness may occur. Canker sores are not contagious in nature. They, normally heal within one to three weeks without any specific treatment, although the pain normally goes away in 7 to 10 days. On the other hand, severe canker sores may take up to six weeks to heal.

How Is a Canker Sore Diagnosed and Treated?

No specific tests are required to diagnose canker sores. These sores can be easily identified through a detailed visual examination. However, if the canker sores are severe and ongoing, tests may be required to check for other health problems. On a general basis, canker sores should be brought to the attention of a dentist or other specialist when these sores –

  • Persist for more than 2 weeks without any improvement
  • If the sores get worse (including while being treated with home remedies)
  • If the sores are accompanied by other additional symptoms like fever, diarrhea, headache and skin rashes.
  • If the sores continuously recur (2-3 times a year or more) or are particularly numerous or severe

There is no specific treatment required for minor canker sores as these tend to heal on their own (within a week or two) without intervention. For large, persistent or unusually painful sores, treatment is necessary. Treatment modalities for this condition focus on treating symptoms, reducing inflammation and improving the healing process by countering secondary effects such as bacterial infections that could possibly slow down the process. Treatment options include – steroid mouth rinses, topical anesthetics, antiseptic ointments/rinses, nutritional supplements and oral steroid medications. Treatment procedures administered by dentists or other specialists must be documented using the right medical codes. Medical billing and coding services offered by reputable billing and coding companies ensure this so that accurate claim submissions are done. ICD-10 diagnosis codes canker sores include –

  • K13.7 Other and unspecified lesions of oral mucosa
  • K13.70 Unspecified lesions of oral mucosa
  • K13.79 Other lesions of oral mucosa

Incorporating lifestyle changes like brushing and flossing teeth on a regular basis, gargling with mouthwash or salt water and avoiding spicy foods can help reduce the intensity of bacterial infections and speed up the healing process. Applying ice or tiny amounts of milk of magnesia to the sores can help relieve pain and promote healing. Rinsing the mouth with a mixture of warm water can also help with pain and healing.

Healthcare providers need to be well-informed about the applicable ICD-10 codes to report canker sores. Dental billing services offered by AAPC-certified coders can help physicians optimize reimbursement for the services they offer.

Teledentistry – Key Benefits and Related CDT Codes [Infographic]

Teledentistry – Key Benefits and Related CDT Codes [Infographic]

Teledentistry is a subset of telehealth that facilitates dental care virtually. This remote dentistry is especially beneficial during the current COVID-19 outbreak. Teledentistry involves diverse modalities including live video (synchronous), store-and-forward (asynchronous), remote patient monitoring (RPM) and mobile health (mHealth). Dental billing services provided by professional medical billing companies can support dental offices in reporting Teledentistry events and in claims submission.

Check out the infographic below


Six Strategies to Boost Dental Practice Revenue

Six Strategies to Boost Dental Practice Revenue

Managing the business side of your dental practice efficiently while providing patients with excellent treatment can be very challenging. Financial success depends greatly on efficient billing and communicating properly with insurance companies to maximize reimbursement. Outsourcing companies that provide dental billing services can make these processes much easier. Here are six strategies to boost your dental practice’s revenue.

  • Perform patient eligibility verification: Successful billing depends on performing dental insurance verification before the date of service. Dental offices need to check the patient’s eligibility, coverage and active benefits with the insurance company. In addition to verifying demographic information, important questions to ask existing patients are whether their dental coverage has changed since their last appointment and whether there were any recent changes in their employment situation. If the patient has a new plan, the office has to obtain the summary of benefits and understand what services are covered under their new plan. According to a recent ADA news report, eligibility verification is especially important as dental offices reopen after the lockdown as they may “find themselves seeing unemployed patients who have lost the coverage they used to have when they were employed”.
  • Review contracted fee schedules: Reviewing contracted fee schedules annually and setting the right fees is crucial for long-term financial success. Take a good look at your fee schedule and see what prices can be increased. Avoid a fixed percentage increase across the board. According to www.marketplace.ada, adjusting your fee schedule can provide extra revenue right away.

    The recently released guidance from the ADA notes that infection control and use of personal protective equipment will substantially increase cost of care for dental procedures. This makes it even more important for dental offices to review and readjust their fee schedules. In order to individually negotiate fee increases with third-party payers, the ADA news report says that dentists may need provide payers with the following information:

    • The desired fee for each procedure code
    • Costs associated with operating the business
    • The date when their fees were last revised
  • The ADA guide notes: “…fee schedules are typically part of the participating provider agreement – a legal contract between the dentist and the third-party payer … It is important to review these documents carefully before trying to project revenues and negotiating fees with the payer.”

  • Establish clear payment policies for patients: Practices should collect the patient’s co-pays or fees not covered by their insurance at the point of service. The best practice is to have a written financial policy so that patients understand their obligations. If these obligations are not met, develop a proactive strategy to collect the payment, such as sending out reminders and statements on a bi-weekly, weekly, or even daily basis. You can also offer an incentive for early payment. Having clear policies and procedures in place can reduce stress, ensure timely collection of payments and keep cash flowing consistently into your office.
  • Ensure an efficient claim submission process: Having a proper system in place for submitting insurance claims is critical to ensuring reimbursement. Techniques for improving insurance collections include submitting claims on a daily basis and setting up a system for reviewing all claims for accuracy before they are sent out. Tracking claim status will tell you about the status of the claims. Contact the insurance company immediately at the first sign of delay or non-payment and investigate the reason so that you can fix it quickly. Outsourcing dental billing to an experienced service provider is one of the best ways to handle the challenges associated with claim submission.
  • Assign the correct codes: Assigning the correct codes for each procedure performed is essential for successful dental billing. Practices need to have a proper understanding of the CDT and ICD code sets and when to use them. Each of these code sets has a specific purpose and payers have their own rules regarding the use of these codes for claim submission. Code changes occur every year and practices should review and note the changes for frequently used codes most often used and evaluate how they are affected.

    If the code reported does not accurately represent the procedure performed, it can result in allegations of fraud. While a carrier may change a dentist’s submitted procedure code to a less complex or lower-cost code, dentists should always take care to report the accurate code to describe the procedure performed. One example of this is with regard to alternating codes D1110 and D4910. In an RDH article dated March 1, 2019, Mark Rubin, JD, legal counsel for the American Dental Association, said, “Knowingly alternating D1110 and D4910 to maximize insurance benefits constitutes fraud. We must code for the procedure being performed. By doing otherwise, the attorney general could make a convincing case for prosecution.” Clinical need should determine treatment, not just what is considered a covered services.
  • Track claims: Dental practices should have proper systems in place to track claims. In fact, this is one of the most important services provided by a dental billing company. They regularly monitor claims on the dental practice management software and review insurance related reports generated by the system. This ensures timely follow-up from claim submission to payment posting. If a claim is rejected, a dental billing service provider will appeal it, make the necessary adjustments, and resubmit it in a timely manner.

Today, many dentists are realizing that outsourcing dental billing is a cost-effective solution that can increase practice revenue. Companies that provide dental billing services have a comprehensive understanding of the ins and outs of insurance and can ensure efficient claims submission to maximize practice reimbursement. Partnering with a dental billing company would be more economical than hiring an in-house team as there would be no sick time, insurance, vacation, time off, or employment taxes to pay. Outsourcing would also free up staff to focus on patient care.

Using CDT, CPT and ICD-10 Codes – What Dental Practices Should Know

Using CDT, CPT and ICD-10 Codes – What Dental Practices Should Know

As dentists focus their time and energy on treatment, they need to pay attention to the revenue side of their practice. One common concern for many dental practices is about assigning codes to report various procedures for reimbursement purposes. In fact, many practices rely on outsourced dental billing services to manage this. Success with dental billing depends to a great extent on having a proper understanding of the various code sets – CDT, CPT and ICD – and when to use them. Each code set has a different purpose and each payer has their own rules for claim submission using these codes.

CDT Dental Codes

The CDT code set maintained by the American Dental Association consists of procedural codes for oral health and adjunctive services provided in dentistry. Each alphanumeric CDT code begins with the letter ‘D’ (the procedure code) and is followed by 4 numbers (the nomenclature). CDT codes are used by dentists to report dental procedures in claims to insurance companies. CDT codes also help dentists achieve uniformity, consistency and specificity in documenting dental treatment accurately in the electronic health record. CDT codes are updated and revised annually.

The CDT Code set categorizes codes by type of service: diagnostic, preventive, restorative, endodontics, periodontics, removable prosthodontics, maxillofacial prosthetics, implant services, fixed prosthodontics, oral and maxillofacial surgery, orthodontics, and adjunctive general services. However, nothing in the CDT supports or indicates limitation of use by dentists – general dentists or specialists – to any categorical section(s) of the CDT Code.

CPT Codes

The CPT code set is maintained by the American Medical Association and used to report medical procedures and services to payers. CPT codes are often referred to as Level I codes.

ICD-10 Codes

ICD-10 codes are diagnostic codes used to group and identify diseases, disorders and symptoms. Each diagnosis code is a unique, alphanumeric string of characters representing a disorder or disease concept. Diagnostic coding involves transforming verbal descriptors of diseases, illnesses and injuries into standardized codes in claims for services.

Code Use in Dental Practices – Key Considerations

Use CDT codes to bill dental services: When to use CDT or CPT codes would depend on the type of insurance to which the claim is submitted matters. CDT is designated a HIPAA standard code set. All claims submitted on a HIPAA standard electronic dental claim must use dental procedure codes from the CDT code version in effect on the date of service. Both in-network and out-of-network providers should use CDT codes for billing dental services on claims to third-party payers.

Consider type of coverage – dental or medical: A major factor governing CDT vs. CPT code use is the type of coverage that the patient has. To assign a CDT dental code on the claim for a dental procedure, the patient must have dental insurance. However, based on the patient’s insurance policy coverage, medical insurance can be billed if the patient received dental care related to a medical condition. As medical plans do not pay for treatment claimed as CDT procedures, dentists need to report the correct CPT codes to describe the medical treatment when submitting claims to medical plans ( Examples of dental procedures that can be billed to medical insurance include:

  • All oral and dental procedures associated with any kind of traumatic injury to the mouth
  • Exams and consultations when oral cancer screening is done, and in preparation for any other medically billable procedure
  • Emergency treatment of oral inflammation and oral infections
  • Diagnostic, radiographic, and surgical or healing stents
  • Radiographs for certain screening and diagnostic purposes
  • Biopsies and excisions, including smears and brush biopsies
  • Surgery associated with interim and final prostheses necessitated by a traumatic injury or any medical condition

However, to bill medical insurance, the dental code intended to be used should have a compatible medical code. This can be identified by cross referencing with the CPT book. Examples of procedures that have a compatible CPT code are:

  • Alveoloplasty w/ extractions per quadrant D7310 / 41874
  • I & D of abscess – intraoral soft tissue D7510 / 41800

The standard practice is to submit the dental claim first and then, if it is denied, submit a medical claim.

Coming to diagnostic codes, ICD codes may be used along with CDT codes on claims submitted to dental benefit plans when needed but are always required on claims for dental services submitted to medical benefit plans. ICD-10 codes in claims filed for dental benefits inform the payer why the procedure was performed and the associated disease, illness, symptom or disorder. The ICD-10 code categories K00 to K95 which describe diseases of the digestive system include diseases of the mouth and conditions treated by dentists. The appropriate diagnosis code should be selected based on the patient’s present condition(s).

Using the correct codes and ensuring proper clinical documentation is essential for timely and appropriate reimbursement as well as to avoid charges of fraud or violations of state or federal law, including noncompliance. Adding to the complexity is the fact that every payer/insurance carrier has their own rules regarding coverage of certain dental expenses. Other areas of concern in dental practices include appeals processes, understanding an EOB, credentialing with medical carriers, and dental insurance verification. The good news is that outsourcing dental billing to an expert can go a long way in ensuring correct code use and efficient claim submission.

Dental Core Build-up – Handling Core Reimbursement Challenges

Dental Core Build-up – Handling Core Reimbursement Challenges

Large amounts of decay or sizable cracks can leave a tooth very fragile, and in need of a crown in order to restore and protect what’s left of the original tooth structure. Core buildup is a restorative procedure where the missing portion of the tooth is restored with a dental filling material in order to support the crown restoration. The core build-up rebuilds the internal anatomy of the tooth structure as prepared for a crown. General dentists and other specialists need to properly evaluate whether there is enough structural integrity remaining to support a definitive crown by a core buildup alone or use an endodontically retained post to secure the core foundation to the root.

Indications of a Core Buildup

A core build-up must be necessary for crown retention to be considered a build-up. The core build-up should rebuild the internal anatomy of the tooth structure as prepared for a crown.

If your tooth is badly broken or missing in a large volume (due to decay), an artificial crown may be indicated to restore the function and appearance of the tooth. However, the remaining portion of the tooth can be so small that it is not adequate enough to support a dental crown. A certain amount of supporting tooth structure has to be present to support a dental crown so it can perform successfully over the long term. The rebuilding process is done with a filling material which is called a core buildup. The purpose of the core buildup is to replace the missing tooth structure, create ideal geometry for the crown restoration and protect integrity of the tooth.

Core Buildup is not covered for the following –

  • As a filler to correct irregularities in preparation
  • As a definitive composite or amalgam restoration
  • For retention of intracoronal restorations

D2950 – Buildup versus D2949 – Foundation

Dental insurance reimbursement for core buildups is often challenging. Many dentists routinely remove all existing filling from a tooth when they do a crown preparation. This can leave several irregularities, undercuts, and divots. The dentist further places a material to fill in these irregularities, so that the final shape of the prepared tooth is “ideal”. This is often confused with a D2950 buildup, which is a similar procedure but is done for a very different reason.

D2950 – Core Buildup, Including Any Pins

  • Descriptor was changed in CDT 2014 – it was simplified to clarify the purpose and intent of a buildup.
  • CDT 2014 descriptor – “Refers to building up of coronal structure when there is insufficient retention for a separate extracoronal restorative procedure.”
  • There is no longer a reference to “tooth strength” in the descriptor.
  • The purpose of a buildup is to help hold the crown on when there is not enough tooth structure left. In other words, if a buildup is not done, then the crown would not stay on.
  • The CDT 2014 descriptor also states “A core buildup is not a filler to eliminate any undercut, box form, or concave irregularity in a preparation.”
  • It is not appropriate to use this code for fillers or bases (included in restorative procedure itself).

D2949 – Restorative Foundation for an Indirect Restoration

  • New code implemented in CDT 2014.
  • CDT 2014 descriptor: “Placement of restorative material to yield a more ideal form, including elimination of undercuts.”
  • The procedure involves placing a restorative material in the tooth for purposes other than helping the new crown to stay. These purposes include – blocking out undercuts, eliminating a box form, filling in voids in the prep, filling in a concavity and making the shape of the prepped tooth more ideal in contour.
  • This procedure is what many dentists were previously doing, but incorrectly submitting as a D2950 buildup.

Some of the important points to note here are –

  • There is a difference between a buildup and a base, liner, or foundation.
  • Placing a restorative material in order to protect pulp is not a buildup.
  • Placing a restorative material in order to idealize the prep is not a buildup.
  • Placing a restorative material in order to eliminate undercuts is not a buildup.
  • Placing a restorative material in order to bond tooth structure, cusps, or cracks together is not a buildup.
  • When there is sufficient tooth to retain a crown, then the shape or size of the crown prep doesn’t matter; the restorative material placed is not a buildup.

Core Buildup Post and Core and Pin Retention – Coverage Guidelines

Post and Core

Post and core are indicated for the following:

  • For teeth with significant loss of coronal tooth structure in endodontically treated teeth in which insufficient tooth structure remains to adequately retain an indirect restoration
  • For Posts – when there is inadequate remaining tooth structure to support a core

Post and core are not indicated for teeth with short roots. When anatomic features are available to retain the core (e.g., when canals and pulp chamber can retain a core), a Post is not indicated.

Pin Retention – This procedure is indicated for teeth with significant loss of coronal tooth structure to allow retention of a direct restoration.

Pin retention is not covered for the following –

  • For restoration of teeth with significant malocclusion
  • If the tooth cannot be properly restored with a direct restoration due to anatomic or functional considerations

Post Removal

Post removal is indicated for the following –

  • When there has been loss of adequate retention
  • In case of tooth fracture and/or Post and core
  • When there are recurrent caries associated with Post and core
  • When access is needed to root canal system for non-surgical endodontics
  • When the tooth has a reasonable long-term prognosis for a new restoration

Coverage Limitations

  • Pin retention and Post and core can be subject to a 12-month waiting period
  • Pin retention is limited to 2 Pins per tooth
  • Re-cementation of Post and core is limited to those performed more than 12 months after the initial insertion

Reimbursement Challenges

The code used for core buildup D2950, is often misused by many dental practices. The existence of a CDT code does not necessarily mean that the procedure is covered or reimbursed by a dental benefits plan. The code D2950 usually applies to teeth that do not have enough tooth structure to support a crown. Typically, 60% or more of the tooth is missing in these instances.

In most cases, a core buildup is reimbursed for a crown placed after endodontic seal because it is common for severe loss of tooth structure from decay. If the procedure is billed on the same day as a root canal, the procedure may not be covered as it will be considered inclusive of the root canal fee. Payers may not provide coverage for a buildup unless there is a crown being placed and often times will not pay for the buildup without the seat date of the crown provided.

Some insurance companies consider core-buildup as part of a crown procedure and thus deny payment towards the D2950 code. In fact, numerous dentists have lodged complaints with the American Dental Association (ADA) Center for Dental Benefits, Coding and Quality, and its staff after third-party payers denied claims for crown procedures. Dentists informed the ADA that this procedure is often bundled with a crown procedure by third-party payers, since a core buildup can be considered part of the crown preparation. Bundling of separate procedures to limit a benefit is against ADA policy.

To minimize claim denials for core buildups, documentation of the condition that resulted in the buildup should be provided in the initial claim submission. This must essentially include documentation indicating that the tooth was broken down to the extent that a buildup was necessary for crown retention. Also, including Pre and Post Op xrays can increase the chances of claim approval.

Health insurance payers may deny payment for the following reasons –

  • A cracked tooth. Cracked tooth syndrome occurs when a tooth has a crack that is too small to show up on X-rays or is under the gum and challenging to identify. Claims for cracked tooth syndrome often get denied because radiographs do not show the cracks or make it clearly visible.
  • Some dental plans cover crowns when the teeth are broken down and have extensive structural damage (due to dental disease or accidental injury). However, if the third-party payer doesn’t see evidence of that, the claim may be denied.
  • Claims may also be denied if the dental plan’s consultant indicates that the tooth has a poor prognosis. In addition, claims for abrasion and attrition are typically denied.

Knowing when to bill for a core build up has proved to be somewhat challenging in the dental world. As CDT codes are subject to frequent changes (which are often difficult to understand), billing and coding for various dental procedures, such as the D2950, and getting claims approved can also be quite complex. Claim denials can have a significant impact on patients and dentists. Dental practices, in such situations, can rely on outsourced dental billing services to overcome these challenges. It is very important for dental practices to understand the common billing and coding points that can largely affect their bottom-line.

Even in the face of denials of claims for core buildups, dentists need to treat patients with appropriate care regardless of the patient’s insurance coverage. The dentist must explain in detail why a specific procedure may not be covered before initiating the treatment procedure, as to avoid a potential large unexpected bill on the patient’s part in the future.

Applicable CDT Codes

  • D2949 – Restorative foundation for an indirect restoration
  • D2950 – Core buildup, including any pins when required
  • D2951 – Pin retention – per tooth, in addition to restoration
  • D2952 – Post and core in addition to crown, indirectly fabricated
  • D2953 – Each additional indirectly fabricated post – same tooth
  • D2954 – Prefabricated post and core in addition to crown
  • D2955 – Post removal
  • D2957 – Each additional prefabricated post – same tooth
  • D2999 – Unspecified restorative procedure, by report

Dental billing services provided by experienced by dental billing companies are a great support for practices to meet their billing and claim submission requirements. Such companies will provide the services of skilled AAPC-certified coders and expert billing specialists who can ensure that your practice has fewer unresolved dental claims.