UPDATED with Survey- Medicaid Dentists: Lack of Use of D1352 Is Causing Audits and Recoupments

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MEDICAID DENTISTS:  Please take our confidential and anonymous five-question survey about D1352.  It is basically a simple Yes-No questionnaire.  It takes less than a minute.   SURVEY IS NOW CLOSED.

Back in late 2011, the ADA added several new codes to the CDT (Current Dental Terminology) manual.  One of these codes was D1352 which is defined as a “conservative restoration of an active cavitated lesion in a pit or fissure that does not extend into dentin; includes placement of a sealant in any radiating non-carious fissures or pits.” Casually, it is called a shallow filling.

Used in Texas since 2012

This new code was added to the December 2012 Texas Medicaid providers manual as a line item. There was no announcement about its inclusion, but it marked a change in that a Medicaid dentist could no longer remove the decay, place composite on the tooth, and always consider it a D23xx filling for billing purposes. Dentists who finished dental school prior to 2012 were immediately at an educational disadvantage about this new code.

Lack of use causing audits and recoupments

TDMR has learned that some dentists have recently come under investigation by Texas HHS-OIG and DMOs for not using this D1352 code but instead billing for a regular filling using D2391.

Dentists not familiar with it

Some of the dentists apparently have reported that they didn’t know anything about this newer code.

Regardless, this incorrect billing is triggering audits and recoupments.

We just wanted to let the Medicaid dental community know about this.

8 Responses

  • Once again, the HHS gets to play overseer in the honest autonomy of the practicing dentist, whether or not a lesser, and lower paying code, has been created in 2012. ANother outside entity acting as though they are the dentist. Next thing will be a code that specifies caries in the outer 1/3rd of the enamel, not just NOT in dentin, and that code will reimburse less yet. That’s in spite of the fact that 1000 dentists will give 2000 results in a caries calibration study, and that enamel caries on the occlusal surfaces do not reveal radiographically. C’mon…do the right things, Doctors, but also call it what it is, and document to support your claim…and pay us for the work we do!!!!!

  • Not trying to be argumentative, but every provider (not just dentists) that enroll in the Texas Medicaid Program sign a Provider Agreement which states:

    “1.1 Agreement and documents constituting Agreement.

    The current Texas Medicaid Provider Procedures Manual (Provider Manual) may be accessed via the internet at http://www.tmhp.com. Provider has a duty to become educated and knowledgeable with the contents and procedures contained in the Provider Manual. Provider agrees to comply with all of the requirements of the Provider Manual, as well as all state and federal laws governing or regulating Medicaid, and provider further acknowledges and agrees that the provider is responsible for ensuring that all employees and agents of the provider also comply.”

    Under Chapter 4 Section 4.3 (Documentation Requirements) of the Children’s Services Handbook (which is specific to Dentists), it states “Any documentation requirements or limitations not mentioned in this manual that are present in the Code of Dental Terminology (CDT) are applicable. The written documentation requirements or limitations in this manual supercede those in the CDT.”

    This verbiage has been present in the Provider Manual since at least the late ’90’s. The American Dental Association publishes CDT and since at least year 2000, the code for a full restoration D2391 (previously D2385/D2380 – posterior restorations) has indicated that it is used to restore a carious lesion into the dentin. Private insurance companies as well as Medicaid follow CDT as a minimum and may or may not impose additional limitation like prior authorization or periodicity. I’m not sure private insurance or the State can notify every provider of every code that is added/removed/changed. At some point the providers and their staff have to do some self-education too.

    You are correct Dr. Shea; most occlusal caries will not show up on radiograph to determine depth, but a post-operative x-ray can show what, if any, preparation was made and if it extended past the DEJ. In that case it’s not a government agency like HHSC-OIG questioning medically necessity of a procedure; they are verifying what was actually done; a D2391 or D1352. Big difference.

    When providers sign a contract and agreement with the State, there is an expectation that the provider will educate themselves of the policy and rules (in this case the Provider Manual and CDT). Unfortunately, ignorance of the rules and policy cannot be used as a defense when it comes to overpayments.

    • Joe Knows should change his or her name to Joe knows nothing about dentistry. A non-dentist arguing dentistry against a professional dentist. This is a shame and a huge flaw in a broken system.

    • Joe Knows: In reference to your statement:

      “In that case it’s not a government agency like HHSC-OIG questioning medically necessity of a procedure; they are verifying what was actually done; a D2391 or D1352. Big difference.”

      Verification of what was already done can mean that dentists begin a procedure to evaluate the extent of an early defective groove, suspect caries, open the groove and, viola, it’s into the dentin. That’s an easy call – is dentinal caries-D2391. But there are those formerly called Preventive Resin Restorations that were not devoid of caries without pit and fissure enameloplasty and minor excavation, that go to the dentinoenamel junction, yet are not completely unaffecting the dentin – it just looks ok, and is hard to an explorer. Here’s where all that cariology, and calibration go haywire. I might call it good, and place a composite here, after taking time to likely anesthetize the patient, manage behavior, isolate the tooth/teeth, and technically have possible caries truly into the dentin. But it looked ok to stop here, just to not thwart being conservative, and get to utilize the D1352 code.

      Devil’s advocate here: But what of the provider who isn’t conservative, and says, “Screw this. I’m going 0.5mm more, get the stain out, and then place a bonafide dentinal restoration – D2391. I’m not messing with these nuances, and I am going to get paid for it.” That restoration will radiographically stand up to scrutiny against the code used, and the entry into the dental record. But was it truly necessary? Or the provider who does the legit DEJ access, but has the conservative mindset that it wasn’t really a true dentinal/enamel restoration – that it was a conservative enamel-only (clinically, not histologically) and under bills the procedure?

      This micro classification of restoration size vs. billable coding is defensible, in theory. But clinically, it is a hell of a nuance to start tripping up the honest dentists who are good at calling a spade a spade, and the shysters who can game the system all day long. The coding, and the subsequent radiographic surveillance is an unfortunate outcome of a system that underpays dentists for what they do, and overpays them for what they don’t do. No coding is going to fix the ethical flaws. That begins in dental school, and in the admissions process – the crook is not made in school, the crook is fostered/fertilized in school.

      • I appreciate all of the comments on defining 2391, and 1352. I respect that we need procedure codes. At the end of the day procedure codes in Medicaid dental care are manipulated by HHSC and the DMO’s. Let me explain. There are many codes in the CDT that are like or similar. For example on a full coverage adult crown there are about 10 different codes or types of crowns a dentist can use for treatment of an adult tooth. These codes in Medicaid dental care should all be the same fee. Instead The DMO’s see the lowest fee on these codes and push a dentist in that direction. Frequently, the low paying fee, is not the best choice for the patient, so a dentist is forced into a corner of violating a standard of care or doing the crown the DMO recommends because it pays the lowest. Thus the dentist is punished for following the codes of the DMO. If all these codes are paid the same, the dentist can do the crown he or she believes is best for the patient, and at a standard of care he or she is comfortable with. The ethical dilemma starts when similar or like codes are given different fees. Remember the fee is still a significantly discounted fee from UCR fees.
        One other example is in pediatric crowns, there are again 4-5 types of crown a provider can use. These again are all paid at different rates. Why? They all accomplish the same thing. Let the provider decide which is best without having to be paid the lowest fee.
        This is the real dilemma with the 2391 and 1352, Truthfully these procedures are so similar, it is not even worth notating the difference with a different fee. They are slightly different yes, but they really take the same amount of time and effort and should be treated the same. One goes 1/2 mm deeper into a tooth. These procedures should have the same fee. If procedures are so similar, they should be treated that way instead of attempting to create an ethical dilemma that should not even be one. There are even occasions where you may be into the dentin on one side of the restoration, but not the other. Then what is appropriate a 2391 or a 1352. The ethical dilemma starts when DMO’s see this as a money saving opportunity, rather than a similar or like code that should be paid exactly the same way.
        A dentist should not have an ethical dilemma every time they do an occlusal filling because of 1/2 a mm of tooth on an occlusal surface. If HHSC and DMO’s would quit baiting dentists with these type of code dilemma’s, perceived dental fraud would be reduced by 50%. DMO’s are constantly looking for a code that pays less that is similar, so they can push it on their providers just like they have done with the 1352. We should continue to support dental coding, but recognize the irregular billing that can occur when like or similar codes are treating with differing fee’s.

  • In response to DDS, Joe Knows is not a dentist and would never try to evaluate medical necessity of a procedure nor try to radiographically determine what was actually performed vs. what was billed. I don’t know what you read in my response that gave you that impression. Government agencies, insurance companies who conduct reviews or inspections would have (should have) a licenced dentist making these call all the time. In any contested hearing a non-dentist who made a decision to question a licensed dentist would not last two minutes in a court proceeding. I don’t believe there’s a flaw in the system to the extent you would like to make it out to be. If you do know of one, I’m sure we would all like to know about that. I would not endorse that kind or review or investigation.

    I was simply trying to point out that when you accept Medicaid payment and more than likely any insurance payment for full restorations like D2391 you are agreeing to the policies, rules and regulations in the respective provider manuals and coding by the ADA. I cannot say that these entities are always going to be correct if they deny or cutback a code, but they have an obligation (and a requirement if they are a government agency) to monitor excessive treatment, unnecessary treatment and inappropriate billing. It’s not going to go away. My wife and I have been going to the dentist for 35 or more years; our children have been going for over 10 years. There have been a total of 3 restorations done in that time between all of us. I would say we probably do the bare minimum when it comes to oral hygiene. Brushing twice a day and not all that consistent with flossing. I know many of my family and friends who would have the same story. BUT Medicaid dentists (NOT ALL OF THEM) seem to find the need to “perform” 10, 15, 20, 25 full restorations in ONE VISIT on MULTIPLE children and teenagers consistently throughout the practice over a significant period of time? Can you explain that? Additionally all these DEJ “fillings” seem to be on the buccal, lingual and occusal; never inter-proximal? Can you explain that? Can your colleagues explain that? Can TDMR explain that? Can you not see why a government agency or an insurance company would be interested? It’s unfortunate that you all cannot see the breadth of this problem and that’s because you don’t have the same access to information as the oversight entities do. Sometimes good dentists get caught up in the enforcement, policy, rules, etc. that materialize because many of your colleagues are not honest dentists who have the PATIENTS’ best interest at heart. That’s unfortunate.

    Dr. Shea, you certainly sound like a very conscientious dentist and probably practice conservative dentistry. If that is true, you would more than likely never be “on the radar” for a review or investigation. If you did happen to be flagged for some review or audit, I suspect you could defend your decisions, your work and your billing. There are others however, that bill aggressively, overtreat, aggressively overbill and sadly, they terrify young children needlessly all in the name of $$. I would never want good dentist unnecessarily investigated.

  • Joe Knows: Amen! Well said! I would suspect my nefarious colleagues do the massive “whole mouth restoration thing in buccal, lingual, and occlusal “defects” because they cannot be accurately questioned with post operative radiographs, and it is somewhat common to see these defects in more of the population where incomes are lower, oral hygiene lacks, and dental IQ is lower. I’m not judging the demographic, but that’s the way it pans out. The problem, as you point out correctly, is there is a propensity of billed surfaces that lean to the less able to be surveyed. Also, there are many conflicting philosophies taught and researched regarding placement of stainless steel crowns and performing pulpotomies and pulpectomies on primary teeth. This tends to be another contested and attempted justifiable procedure set performed in the OR or in-office sedation scenario, set up as an “efficient, patient-safe, and proper way to approach the public health problem or rampant caries.” The underlying altruistic claim is “get it over with and get the disease removed.” That is only valid on a case-by-case basis, not as a philosophy of clinical treatment.

    Many times I quit referring to particular pediatric dentists because of their aggressive, non-educational approach to the patient, parent, and problem. To their defense, the Medicaid system is short-handed on providers, the backlog is huge, and the need is unfathomable. Still no excuse to overtreat and overbill.

    To be honest, Joe, because of the corruption, not just in the Medicaid system, but within the insurance industry itself, the state dental boards, organized dentistry, and the metastatic dominance of corporate dentistry as a “better model” for patient care (cheaper), I quit dentistry at 54 years old. I had it with being a pawn, a player, a peon. I had my career dictated by the action of the few who ruined it for the many. I do not trust my colleagues, because I know too much.

    You are right, Joe…it’s broken, and it is not easy to explain why the system failed – too many moving parts and too many people profiting from it all.

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