Periodontal claims submission: avoiding and overcoming denials
Table of Contents
- The 3 most common causes of periodontal denials
- Preventing periodontal denials
- Tips for successful appeals
How many times have you been frustrated when periodontal claims come back denied or downgraded, despite your best efforts? If the answer is "too many times to count", don’t worry – you are not alone, we have some Wisdom to share! Periodontal health is the cornerstone of a vibrant smile and overall well-being. Yet, despite the meticulous care and attention devoted to periodontal treatments, dental practices often encounter a frustrating hurdle: periodontal claim denials.
In this blog, we’ll dive deep into the complexities of periodontal claim denials, uncovering the root causes, providing strategies to prevent them, and offering expert tips for appealing denials when they do occur.
The 3 most common causes of periodontal denials
Coding errors
Incorrect coding is one of the leading causes of claim denials. This might include using a non-covered code, applying an outdated code, or failing to specify the correct sites impacted by the treatment. In some cases, an incorrect code can even prevent the claim from being processed in your clearinghouse.
Example: If a scaling and root planing procedure is not properly coded with the correct quadrants or site-specific codes, it can be denied for lacking necessary detail. Make sure to review the codes each time to ensure they match the treatment provided.
Documentation deficiencies
Proper documentation is critical. Inadequate documentation of the patient's periodontal condition, treatment plan, and post-operative care can lead to denials. Insurance companies require clear and comprehensive records to justify the necessity of the treatment provided.
Example: If the treatment documentation does not include detailed clinical notes or a treatment plan that clearly outlines why the procedure was medically necessary, the claim may be denied.
Coverage limitations
Many insurance plans impose limitations on periodontal services, such as frequency restrictions, waiting periods, or pre-authorization requirements. Failure to understand and adhere to these limitations can lead to claim denials.
Example: A patient who received periodontal treatment six months ago may be denied if their insurance plan only covers one treatment per year. If a thorough insurance verification was not obtained before beginning treatment, the claim may also be denied.
Preventing periodontal denials
Let's look at the most common reasons for denials, in reverse, and discuss how to ensure you are prepared for submitting periodontal claims to insurance.
Comprehensive documentation
Ensure thorough and accurate documentation of the patient’s periodontal assessments and clinical treatment notes. Comprehensive notes, including patient history, diagnostic tests (like probing depths), and treatment plans, are crucial. Additionally, include all supporting documents to back up your claim.
We recommend using our clinical note template for scaling and root planing to ensure all the necessary information is included. Additionally, use our attachment cheat sheet to guarantee that every piece of documentation is submitted with the claim. You can download our full set of dental billing cheat sheets here. Always ensure that you have a recent full mouth series (FMX) on file when submitting claims for scaling and root planing, as bitewings or panoramics alone may not sufficiently support the need for treatment.
Accurate coding
It’s important to use correct procedural codes and modifiers that accurately reflect the nature and severity of periodontal disease and the treatment provided. Missteps here can lead to delays or denials. For coding help, we recommend the ADA’s coding books, which are trusted in the industry, or checking out this helpful blog by RDH Magazine for additional insights.
Example: For scaling and root planing, you may need to specify whether the procedure was done on a quadrant basis or as a full-mouth treatment. Incorrect modifiers may result in the denial of coverage.
Insurance verification
Before initiating any periodontal treatment, always verify the patient’s insurance coverage. This includes checking for limitations, pre-authorization requirements, or frequency restrictions.
Tips for successfully appealing periodontal claim denials
Sometimes, despite our best efforts, claims are denied. Here’s how you can increase your chances of successfully appealing a periodontal claim:
Document everything:
When submitting an appeal, include all necessary documentation, including detailed clinical notes, radiographs, and a thorough explanation of why the treatment was necessary, which should be part of your clinical notes during diagnosis as well as treatment.
Understand the plan’s requirements:
Refer to the patient’s policy and provide a detailed response that addresses specific denials based on limitations or exclusions within the plan. Also, be aware that the denial or information request may require to to send additional information to the support the claim in a different manner than regular claims submission.
Stay organized:
Create a tracking system for denied claims so that appeals are timely and follow-up is consistent. Keep all notes and reference information within the claim notes in your practice management software. This shows the insurance company that you are diligent and serious about resolving the claim.
Periodontal claims may be one of the most challenging areas of dental billing, but with the right strategies in place, you can reduce denials and streamline the claims process. From ensuring accurate coding to maintaining comprehensive documentation and verifying insurance details, taking these steps will help you prevent common pitfalls and get paid faster. If you do encounter a denial, use the tips we’ve shared for a successful appeal process and keep your practice moving forward.
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