Billing insurance for orthodontic services differs from general dental billing due to the complexity of treatment plans, extended treatment durations, and varying insurance coverages. The goal is to ensure that the practice maximizes reimbursement while providing a smooth experience for patients.
Key Components of Orthodontic Insurance Billing
CDT Codes for Orthodontics:
Accurate use of CDT (Current Dental Terminology) codes is essential for proper billing. Below are commonly used codes for orthodontic services:
Initial Exam and Diagnostic Records:
D0150: Comprehensive Oral Evaluation
D0330: Panoramic Radiographic Image
D0340: 2D Cephalometric Radiographic Image
D0470: Diagnostic Casts
Orthodontic Treatment:
D8010: Limited Orthodontic Treatment of the Primary Dentition
D8020: Limited Orthodontic Treatment of the Transitional Dentition
D8030: Limited Orthodontic Treatment of the Adolescent Dentition
D8040: Limited Orthodontic Treatment of the Adult Dentition
D8050: Interceptive Orthodontic Treatment of the Primary Dentition
D8060: Interceptive Orthodontic Treatment of the Transitional Dentition
D8070: Comprehensive Orthodontic Treatment of the Transitional Dentition
D8080: Comprehensive Orthodontic Treatment of the Adolescent Dentition
D8090: Comprehensive Orthodontic Treatment of the Adult Dentition
D8680: Orthodontic Retention (Removal of Appliances, Construction, and Placement of Retainer)
Additional Codes for Adjustments and Appliances:
D8670: Periodic Orthodontic Treatment Visit (As Part of Contract)
D8660: Pre-Orthodontic Treatment Visit
D8691: Repair of Orthodontic Appliance
D8692: Replacement of Lost or Broken Retainer
D8693: Re-cement or Re-bond of Retainer
Pre-Authorization Process:
Always verify insurance benefits before starting treatment. Most insurance plans require pre-authorization for orthodontic services, which involves submitting a treatment plan, diagnostic records, and an estimated timeline.
Ensure that the pre-authorization request includes:
Patient’s complete information.
Orthodontic diagnosis and treatment plan.
Relevant CDT codes.
A detailed narrative that explains the necessity of treatment.
Writing Effective Narratives:
Insurance companies often require a narrative to justify the need for orthodontic treatment. Narratives should include:
The patient’s chief complaint (e.g., crowding, overbite).
Clinical findings (e.g., malocclusion classification, spacing issues).
Impact on the patient’s oral health (e.g., speech issues, chewing difficulties).
Be specific and concise. For example:
“Patient presents with Class II Division 1 malocclusion with a 7mm overjet, contributing to difficulty in chewing and speech articulation. Treatment aims to correct occlusal disharmony and improve function.”
Submitting Claims:
Use the ADA Dental Claim Form for submission. Key sections to complete:
Patient and Subscriber Information: Ensure all fields match the insurance card details.
Billing Provider Information: Use your practice’s correct NPI and TIN.
Service Dates and CDT Codes: Accurate dates of service and corresponding CDT codes.
Include necessary attachments like radiographs, photographs, and narratives.
Checking and Understanding EOBs (Explanation of Benefits):
Review EOBs carefully to understand what was covered, denied, or paid. Key aspects to check:
Ensure the insurance processes the correct codes and amounts.
Compare expected reimbursements to actual payments.
Address any denials immediately by contacting the insurance company or submitting an appeal with additional documentation if needed.
Handling Denials and Appeals:
Common reasons for denial include lack of medical necessity, missing information, or incorrect coding.
Steps to appeal:
Review the denial reason and gather all supporting documentation.
Submit a clear and concise appeal letter, addressing the specific reason for denial and including any missing information or clarifications.
Tracking Payments and Patient Balances:
Orthodontic treatments are typically paid in installments. Set up a tracking system to monitor:
Insurance payments versus patient payments.
Ensure that all payments are aligned with the contractual agreement.
Communicate clearly with patients about their financial responsibilities, including any balances after insurance payments.
Additional tips to Maximize Reimbursement for Clear Aligners:
Verify Coverage for Clear Aligners: Not all orthodontic benefits include clear aligner coverage. Be explicit in verifying if clear aligners are included and whether any limitations apply (e.g., age restrictions, frequency of coverage).
Patient Co-pay and Out-of-Pocket Considerations: Clearly communicate the financial responsibilities of the patient, including co-pays, deductibles, and any non-covered services related to aligner therapy.
Best Practices to Keep in Mind
Regularly Review and Update CDT Codes:
CDT codes are updated annually. Ensure your billing team is using the most current codes and guidelines.
Maintain Detailed Patient Records:
Accurate and comprehensive records help support claims, especially when appealing denials. Include detailed progress notes, treatment modifications, and patient communications.
Build Relationships with Insurance Representatives:
Establishing good communication with insurance reps can help when navigating complex cases or appeals.
Train Staff Continuously:
Regular training sessions on coding, billing updates, and handling patient inquiries can prevent common errors and improve efficiency.