By Carol Tekavec, CDA, RDH

Increased utilization review has put a spotlight on radiographs. The need for documentation of the reasons radiographs are taken is now essential for many plans to pay claims. Previously, four bitewings were benefited automatically once or twice a year by carriers; now many are requiring evidence to justify their exposure. The ADA Web site features "Guidelines for Prescribing Dental Radiographs," which outlines current thinking on radiographs for various categories of patients. While the final judgment as to which X-rays are necessary remains with the dentist, the "Guidelines" provide a powerful argument for insurance carriers looking to limit expenses. For example, according to the guidelines, an adult "recall" patient, with no clinical caries or high-risk factors for caries, should receive posterior decay detecting radiographs (BWS) only once every 24 to 36 months. Many dentists might feel that that schedule is too infrequent.

Therefore, whenever radiographs are taken, it is recommended that the reason the radiograph is being exposed, and what the radiograph subsequently reveals, be documented in the patient's chart. This eliminates any future question about whether or not the radiograph was "necessary." Even in the absence of insurance issues, detailed documentation for radiographs is suggested. For example, "Suspected interproximal decay maxillary right and mandibular left. Interproximal decay discovered on No. 3 and No. 19."

Radiographs, even when the reason for them is documented, may not be paid, or worse, may be paid now with the payments later demanded back, if pathology or "suspicious lesions" are not revealed. For example, if a patient had documented reasons for bitewings in 2006 and then again in 2007, but no decay or problem was revealed either time, the carrier may not automatically pay for the bitewings in 2008. Or they may pay for the 2008 bitewings at first, and then later request a refund from you. Your chart and progress notes are your only defense against such situations.

Coding for complete series

Dentists typically consider a complete series (D0210) to be seven to 14 periapical radiographs, including the necessary bitewings (two to four). Insurance carriers usually regard seven or more periapicals as a D0210. This means that regardless of the areas exposed, seven periapicals = a complete series to insurance. In addition, many carriers consider a D0330-Panoramic Film to be equivalent to a D0210. To complicate matters further, a D0210 may or may not be subject to an annual deductible.

Some carriers regard any combination of radiographs, such as four bitewings and three periapicals, taken on a given date, which meets or exceeds their allowable payment for D0210, to be equal to a D0210. This means that an actual Complete Series-D0210 may be denied future payment if taken before the usual carrier time restriction (three to five years) ends. (It is a good idea to consult the patient's plan to verify time limits and/or deductibles. Some plans allow payment more frequently than once every three years; some have extended restrictions to once every five years. Some plans exempt this code from an annual deductible; others do not.) If a D0210 code is "used up" by the carrier, payment for a D0330-Panoramic Film at the same appointment or at a subsequent appointment will also usually be denied.

What does all this mean? Insurance restrictions on payment for radiographs vary so much that it is now extremely difficult for a dental office to anticipate the level of reimbursement available to a given patient. Therefore, it is usually best to simply let patients know in advance that the radiographs that are being taken are necessary for a proper diagnosis, and that their insurance may or may not cover the cost. Because patients typically believe that preventive and diagnostic procedures are covered 100%, problems arise when they are surprised after the fact by what their insurance will actually pay. Providing information about the limited nature of insurance "before the fact" is perceived as providing a reason. "After the fact," patients may just assume that excuses are being made.

Carol Tekavec, CDA, RDH, is the president of Stepping Stones to Success and a practicing dental hygienist. She is the author of the "Dental Insurance Coding Handbook" and six patient education brochures which can be read on her Web site. Contact her at (800) 548-2164 or visit www.steppingstonestosuccess.com.