Minimizing Errors in Dental Claims: Insights from an AAPC Audit

Poor dental care can have a significant effect on a patient’s overall health. With the evolving landscape of healthcare, dental services are increasingly becoming an integral part of comprehensive medical care, particularly within population and community health clinics. Many organizations are now formalizing physician-dentist care teams to better serve patients with chronic conditions such as diabetes, cancer, obstructive sleep apnea, Alzheimer’s disease, and pregnancy. This care team approach also addressed patients with social determinants that directly impact their health by providing improved access to dental services.   

The goal of integrated care teams is to address the critical link between oral health and overall well-being. A recent article from the American Medical Association (AMA) titled Time for Dental Care to Be Considered Essential to U.S. Health Care Policy highlighted significant disparities in dental care access due to lack of insurance, particularly among various age, income, and racial groups. Because of these disparities, patients are vulnerable to systemic medical conditions. AMA urges policymakers to prioritize dental care as an essential part of U.S. healthcare policy for all ages. 

With these shifts, new challenges and opportunities are emerging in documentation and coding practices. AAPC Services conducted a case study to evaluate dental claim documentation and coding accuracy, revealing critical areas for improvement in EHR systems, documentation protocols, and provider education.  

The Case Study

Background: Between January and December 2023, AAPC Services audited dental claims for 10 population health and community health centers, reviewing 260 providers and 2,600 claims.  

Results: The audit revealed a 79% accuracy rate for CDT codes with 14% of claims having incorrect coding and 7% representing missed opportunities for additional services. The 14% incorrect CDT codes were primarily due to insufficient documentation, unbundling, and over-coding.   Key Findings:  

1. Radiologic Images (31% Errors): 
Errors involved radiologic images that were either unbundled or lacked sufficient documentation to support the number of films/bitewings billed, as well as medical necessity. Commonly misused CDT codes included:

• D0210: Intraoral - complete series of radiographic images 

• D0330: Panoramic radiographic image 

• D0230: Intraoral - periapical each additional radiographic image 

• D0272: Bitewings - two radiographic images 

• D0220: Intraoral - periapical first radiographic image 

• D0277: Vertical bitewings - 7 to 8 radiographic images 

• D0274: Bitewings - four radiographic images 

• D0270: Bitewings - single radiographic image 

• D0350: 3D photographic image 

• D0367: Cone beam CT image capture with interpretation 
  

2. Oral Evaluations, Screenings, and Consultations (14% Errors): 
Errors were related to the over-coding of oral evaluations, screenings, and consultations. Commonly misused CDT codes included: 

• D0120: Periodic oral evaluation - established patient 

• D0190: Screening of a patient 

• D0150: Comprehensive oral evaluation - new or established patient 

• D0140: Limited oral evaluation - problem focused 

• D0160: Detailed and extensive oral evaluation - problem focused, by report 

• D9310: Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician 

• D9450: Case presentation, detailed and extensive treatment planning 

3. Procedural Errors (32% Errors): 
Errors involved unbundling and/or insufficient documentation of procedures. The top 5 procedural errors were: 

• Intraoral placement of fixation device (Re-cement or re-bonding, sealant repair) performed within the same time limitation 

• Tooth extractions 

• Protective restoration 

• Resin-based composites 

• Crowns 

4. Missed Revenue Opportunities (9%): 
Commonly missed codes included D1330 for oral hygiene instructions. 

5. Missing Elements on Claims (17%): 
17% of dates of service lacked the Universal Numbering System (UNS) for teeth or tooth surfaces on the claim form. 

6. ICD-10-CM Errors & Lack of Medical Necessity (44% Accuracy): 
For audits performed on practices in which their states and payers mandate the use of ICD-10 CM codes to be reported along with the CDT codes, the accuracy was a surprising low of 44% with 13% incorrect due to specificity and/or wrong codes being reported. And 43% of codes which were not reported and should have been to support the medical necessity of service(s) being rendered. 

Root Causes of Errors  

We initiated discussions with various practice locations, managers, and providers to uncover the root cause for these results. We discovered:  

• EHR Limitations: Templates and workflows did not support the clinical needs for dental services, resulting in insufficient documentation. 

• Provider Education: Many providers did not understand the documentation requirements for specific services; they did not have adequate training on documentation and ICD-10 CM coding guidelines. 

• Coding Oversight: Claims were not reviewed by certified coders, leading to coding and billing errors. 

Improving Documentation  

Accurate and comprehensive documentation is crucial for the effective integration of dental and medical services. Improving these practices is essential to ensure seamless service delivery and financial sustainability. Here are strategies to enhance documentation: 

1. Unified Electronic Health Records (EHR) Systems

• Implementation: Use integrated EHR systems that allow both dental and medical professionals to access and update patient records. This ensures that all healthcare providers have a complete view of the patient’s health history. 

• Benefits: Improved care coordination, reduced duplication of tests, and a holistic understanding of patient health. 

2. Standardized Documentation Protocols 

• Implementation: Develop and enforce standardized documentation protocols that detail the required information for dental and medical services. This includes patient history, examination findings, diagnostic tests and procedural details, formal assessments with treatment plans, and follow-up of care. 

• Benefits: Ensures consistency and completeness in patient records, facilitating better care and easier claim processing. 

3. Training and Education 

• Implementation: Regularly train coders, billers, and providers on proper documentation practices. This includes training on new EHR systems and updates in coding standards and guidelines. 

• Benefits: Reduces errors, enhances compliance, and ensures staff and providers are up to date with best practices. 

 
Streamlining Coding & Billing Processes 

Effective coding and billing practices are essential for the financial viability of integrated services. Here are tips to improve processes: 

1. Cross-Train Staff 

• Implementation: Cross-train both the coding and billing staff in dental and medical coding and billing procedures. This ensures that they are equipped to handle claims across the spectrum of services provided. 

• Benefits: Reduces billing errors, improves claim approval rates, and ensures compliance with insurance requirements. 

2. Comprehensive Coding Practices 

• Implementation: Adopt comprehensive coding guidelines that accurately reflect the services provided. This includes using the correct ICD-10 CM, CPT^®, CDT code, and the UNS for integrated services.  

• Benefits: Ensures proper reimbursement, reduces the risk of payer audits, and facilitates accurate reporting. 

3. Compliance Audit 

• Implementation: Incorporate dental claims into your compliance audits program. This includes reviewing the documentation and coding, as well as billing processes such as insurance verification, claim submissions, payment posting and denials.  

• Benefits: Ensures compliance with documentation and billing standards, improves accuracy, identifies gaps in missed revenue opportunities, and protects the bottom line. 

How AAPC Can Help  

AAPC offers a range of tools and services to help healthcare organizations improve their documentation, coding, and billing practices:  

• Codify by AAPC: The preferred coding tool of thousands of healthcare organizations, Codify ensures accurate coding and streamlines documentation practices. 
   

• Practicode: An interactive practicum that provides real-world coding experience, helping coders enhance their skills and reduce errors. 
   

• Corporate Team Training: AAPC offers customizable training for revenue cycle teams to ensure compliance with the latest coding standards and practices. 
   

• Audit Services: AAPC Services’ comprehensive audit solutions can identify coding and billing errors, optimize claim accuracy, and improve revenue cycles. 

Conclusion 

The integration of dental services into overall healthcare presents an opportunity to improve patient outcomes. By focusing on improving documentation, coding, and billing practices, healthcare practices can ensure the highest quality of care, while maintaining financial sustainability. Implementing unified EHR systems, standardizing documentation protocols, and offering comprehensive training are critical to achieving these goals — and AAPC offers solutions to support your organization in these efforts.     

References:
Journal of Ethics
NCBI