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Understanding Procedure Codes: A Practical Look at Risks and Ethics

Posted Dec 14th, 2020 in 2020, the wire, thought leadership

Michelle Budd, D.D.S, Patient Safety Consultant, dentalcorp; Julian Perez, Vice President, Risk Management & Compliance, dentalcorp

Proper procedure coding within your practice is important on many levels, from ensuring accurate payment for dentists to creating a valid record of patient care. Failing to use appropriate procedure codes can lead to all kinds of mischief for dentists as well as poor outcomes for patients. Indeed, accurate procedure coding is a legal requirement with serious consequences for those who fail to abide by the regulations. The following are examples of misconduct that can result from the intentional or mistaken misuse of procedure codes:

1.       Charging fees that are excessive or unreasonable in relation to the services performed;
2.       Charging for services not performed;
3.       Knowingly submitting a false or misleading account or false or misleading charges for services rendered to a patient; and
4.       Falsifying a record regarding the examination or treatment of a patient.

In addition to forming part of the patient record, aiding the billing process, and helping expedite payment, procedure codes can be used to analyze what diagnoses and treatments a dentist has made and to compare one dentist to others with similar practices. The ratio of root canals to extractions or five surface fillings to crowns reveals a lot about how a given clinician practices, their treatment philosophy and even the demographic they serve.

Beyond regulatory liability, inaccurate coding on claim forms can have legal ramifications if the insurance carrier questions the accuracy of the submitted procedures. Delegating the billing process to someone else on the team is not an excuse for failing to use the appropriate code—particularly if there has been a pattern of such behaviour resulting in overpayments. Serious negative consequences can follow even when a clinician provides the appropriate care but leaves the task of selecting a code to an administrative team member who is not properly trained.

If a dental regulatory authority finds a member to have systematically overbilled or overtreated a patient (when the clinical notes and records are poor, it can be hard to differentiate), that practitioner can face disciplinary action. At the same time, insurance companies that suspect misuse or abuse of procedure codes have multiple options at their disposal. Some of these options include:

  • Investigating claims submitted over the previous two-year period or longer. While this doesn’t seem so dire, the time and inconvenience to provide the requested information can be tremendous.
  • Demanding money back. This may be more than just the overpayment. The insurance company will ask for the full amount paid from the treating/responsible dentist.
  • Contacting patients and informing them the fraud department is investigating. This can lead to serious reputational damage and loss of patients.
  • De-listing a dentist or entire office. When an insurance company de-lists a dentist or dentists, it means they will no longer accept claims submitted by them and will not reimburse for treatment received by that dentist. Whether your practice accepts assignment or not is irrelevant. Once an insurance company loses trust, it takes a long time to rebuild it.
  • Reporting a provider to its regulatory authority. A concern with an insurance carrier can become a professional misconduct investigation with the licensing body. The concept of double jeopardy does not apply to your professional license. In egregious cases, the insurance company may even report the matter for criminal investigations.

Understanding the risks of procedure code misuse/abuse is key to ensuring a long and prosperous career as a dentist. With the rise of big data, insurance companies have grown increasingly sophisticated in the way they identify and investigate fraud. Moreover, the Canadian Health and Life Insurance Association (CHLIA) dedicates significant resources to rooting out benefits fraud. CHLIA even has a patient-facing website that advises them to “alert” their insurer if dentists “waive your co-payment or deductible”. Likewise, for those who suspect plan abuse or fraud, CHLIA instructs them to report it.

It goes without saying that intentional overbilling is unacceptable. With regards to inadvertent code misuse, effective risk management strategies are readily achievable. The tips below will help providers avoid triggering an insurance audit. Should an audit occur, adhering to the bylaws and knowing the proper use of codes in the fee guides will help ensure a favorable outcome.

Here are some tips all dentists should adopt in their practice.

Tip 1: Know the most common red flags for insurance companies, which include:

  • Performing complete oral exams based on a defined frequency rather than individual need
  • Billing emergency or specific exams at dental hygiene visits without justification in the treatment notes
  • Coding for freezing with scaling
  • Using a desensitization code for use of topical numbing agents
  • Recording units of scaling/polishing that depart from the bell curve or appear to be based on patient age or insurance coverage, rather than need
  • Submitting claims for a higher than average proportion of surgical extractions and complicated root canals
  • Charging a different code for the same service because the correct code is not covered
  • Failing to attempt to collect co-payments before writing them off
Tip 2: Include the following so that your patient records support whatever you bill:
  •  A diagnosis for each tooth and rationale for the treatment provided
  • The time spent for time-based codes, and the rationale for this amount of time, especially scaling, polishing, oral hygiene instruction)
  • A clear description of the treatment that was done, including materials and methods
  • A description of any complicating factors that made the treatment more difficult (e.g. what made the root canal “difficult access” or in what way did it meet the definition of “calcified”)
Tip 3: Avoid ever having to answer questions like these:
  • Why did all these teeth require a core to be placed on the date of the crown prep?
  • Why does every patient require exactly 8 units of sedation?
  • Why do your patients need a specific exam at the appointment for fillings that were diagnosed at a recent recall exam?
Tip 4: Communicate clearly with your patients about their treatment
  • Patients may be called upon to describe the treatment they received, including the amount of time spent and any complications or additional procedures that were required
  • Document the conversations you have with patients about their treatment in the progress notes
  • Ensure patients understand all fees on their invoice and explanation of benefits before they leave the office


Professionalism is essential when interacting with patients, insurance companies, colleagues, and anyone else you may encounter in your capacity as a healthcare provider. Core to this concept of professionalism is honesty and integrity in financial dealings.

One way to protect the reputation that was so hard-earned is to verify that all codes you bill are supported by the treatment provided as well as the records entered in the chart. This means understanding the procedure codes in the fee guide, taking an active role in assuring the clinic’s billing process is operating as designed, and remaining vigilant so that no additional codes are added. Bill honestly, bill accurately, and you’ll not only do fine—you’ll thrive.

As previously published in the College of Dental Surgeons of Saskatchewan's 2020 Winter Newsletter

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