My article on dental insurance claim reimbursement called “X-rays and Narratives for Crowns, Inlays, Core Buildups” covers the common radiographic and narrative requirements for crowns, inlays, and restorative foundations. Read on for more on the subject of narratives.
What should be in a narrative
I’ve said before that intraoral photography is helpful for crown, onlay, veneer, and core build-up claims, but I strongly recommend documenting the details of diagnosis and treatment in a narrative. Technically, narrative is any written information. This can be one word, one sentence or several paragraphs about the tooth and the treatment. This written information is often submitted on the claim form itself, which is found in Box 35, the “comments” section of the standard ADA claim form. However, this section is limited in characters.
I suggest submitting the narrative information as an additional attachment or enclosure. When done as an additional enclosure, the entire story related to the condition of the tooth and the treatment can be relayed. You can add supporting photos on the same page as your narrative, drawing attention to what you want a clinical claims review team to see. Without conveying all relevant information, medical necessity may not be established by x-ray alone.
Some offices submit a copy of a checklist as a narrative. I think a checklist is a useful way to document findings while in the chair and can serve as a reminder of important specifics to add later to clinical progress notes. I love checklists as part of my workflow, but they just aren’t enough for a strong, compelling, impactful narrative. A well-written narrative can have valuable information and can overturn a negative benefit determination. It’s worth taking the time to process your checklist findings.
Establishing medical necessity
Relevant information to document medical necessity will include caries and dentinal caries, extent of caries as a percentage of the occlusal matrix compromised, amount of remaining tooth structure, symptomatic cracked tooth, and evaluation of the tooth for diagnosis and recurrent caries. Reason for indirect recovery that can not established medical necessity would be wear, tear, abrasion and detachment — all with or without tenderness. Insurance carriers widely have exclusions for these conditions in the absence of dental caries.
When I did peer-to-peer calls, the dentists would say, “But the tooth was sensitive.” When it comes to medical necessity for an indirect restoration, sensitivity—in the absence of dental caries—does not meet the criteria for most carriers. From an insurance perspective, there are ways to combat sensitivity, so restoration is not the only viable option.
Therefore, be careful when restoring worn dentition or lost vertical dimension. While the patient will benefit from treatment, insurance benefits may not be allocated for these services as they are not deemed medically necessary.
Is there caries in the cervical region of the detachment? Has wear started in wear areas? If so, document this in your clinical progress notes and submit them as supporting information for your services in your narrative.
Read more about dental insurance reimbursement…
Clinical optimization of scaling and root planing
Radiographs and narratives for crowns, onlays, core build-ups
Especially cracked teeth
A useful chairside diagnostic tool for indirect reparative therapy that I used commonly in clinical practice was enlightenment. Transillumination had an impact on demonstrating a cracked tooth in a patient. I often obtained photographs for documentation and added a note to my clinical progress notes. However, keep in mind that many insurance carriers will not accept only translucency findings, photographs, or documentation as supporting information to prove a medically necessary loss.
An article by Lubisich et al., “Cracked Teeth: A Literature Review,” discusses enlightenment and its drawbacks. Lubisich stated transillumination as a method that dramatizes all cracks to the point where the lines of madness can appear structural.1 Additionally, there is ample literature supporting the perspective that not all fissures need treatment, a perspective shared by many payers.
An article by Mamoun et al., “Diagnosis and Treatment of Cracked Teeth: An Alternative Paradigm,” reviews common clinical examples of cracked teeth, including cusp fractures, sulcus fractures, and root fractures. The authors go on to explain that a partial fracture is considered repairable and is done to avoid a catastrophic complete fracture, which would be unrepairable with an immediate repair. This article also states that not all cracks and crazy lines indicate the need for full coverage restoration treatment, if not of a structural nature.2
Thus, although a patient may benefit from full restorative coverage as a predictable, long-term, preventive treatment option, dental benefits are allocated only for cases of actual medical necessity. An asymptomatic tooth with crud lines and no structural fissures does not meet the criteria of medical necessity and typically does not benefit because of crud lines alone. I recommend you go further and fully test cracked teeth. Document your test to confirm that the tooth actually has a symptomatic crack that requires full restorative coverage out of necessity.
Scaling and root planing
All the information we have discussed so far is related to indirect rehabilitation therapy. I attended a seminar that suggested escalation narratives and root planing (SRP) claims should report bleeding, connective tissue loss, and active disease process. This is something I did when I submitted claims from my chairside dentistry in private practice. However, after moving into the insurance payer market, it was apparent to me that a narrative has little to no effect on claim reimbursement.
The AI is integrated into many payer workflows and does not consider narrative information, only the presence of visible, radiographic bone loss that meets the specific insurance provider’s criteria (generally 2 mm).
Scaling in the presence of gum inflammation
Now, a claim for D4346, D4910 or D4381 is a different story. For scaling in the presence of generalized moderate or severe inflammation of the gums, full mouth (D4346), markers of inflammation should be documented. The easiest way to do this is to mark the bleeding points while probing. If this is not documented on your periodontal chart, you can document generalized bleeding in the clinical progress notes from the patient’s examination or hygiene treatment.
As a claims examiner, I was more inclined to recommend admission for benefits if the bleeding points were documented on the periodontal chart. Personally, I did not recommend denying benefits in cases where bleeding was not documented on the periodontal chart but was provided in a narrative.
If you receive a negative determination on your claim for D4346 and you have generalized bleeding documented in your clinical progress notes, please submit a copy of your notes in your appeal. But remember, if there is bleeding and radiographic bone loss (usually more than 2 mm, measured from the CEJ to the crest of the bone), the most appropriate code is D4342 or D4341, depending on the number of teeth involved per quadrant. Your claim for D4346 may be rejected because it is not an appropriate treatment to treat areas of bone loss. D4346 is done in the absence of bone loss.
Periodontal maintenance
Periodontal maintenance claims (D4910) sent for clinical review may require a current and complete periodontal chart from the date of service to demonstrate that the patient does not have active disease requiring repeat scaling. Since D4910 involves site-specific scaling, an isolated pocket with bleeding is reasonable. However, if multiple teeth in each quadrant demonstrate an active disease process that cannot be maintained but requires nonsurgical treatment, D4910 may not be allowed. If you receive a negative determination, a narrative may be helpful to explain that although the patient has a reduced periodontium, you believe that their periodontal status can be maintained with D4910, without the need for repeat scaling.
Topical administration of antimicrobial agents
D4381 is the code for the placement of topical antimicrobial agents such as Arestin or Atridox. Each dental payer will have terms regarding whether the placement of these antimicrobial agents is covered by their dental policies—eg. if allowed only after a 90-day healing period after SRP, the number of places allowed per tooth/quadrant/arch/mouth, and if pocket depths greater than 5 mm or 6 mm are considered. The payer may request to see documentation of the lot number and expiration date.
I suggest that you submit a narrative of Arestin or Atridox placement, listing date of service and date of de-escalation. Please state “after the 90-day healing period, for the occasional, residual, non-healing, 5mm+ pocket” along with an updated periodontal chart and include the lot number and expiration date. Using the patient’s medical insurance is a different matter.
Author’s Note: As always, these tips and tricks are not a guarantee of coverage. are recommendations based on hours of clinical review of claims and time spent with insurers. If the services you performed meet their criteria for determining medical necessity, they want to pay you for your dental care.
Editor’s Note: This article first appeared on Through the Loupes newsletter, a publication of Endeavor Business Media Dental Group. Read more articles and subscribe to Through the Loupes.
bibliographical references
- Lubisich EB, Hilton TJ, Ferracane J. Cracked teeth: a review of cinematography. J Esthet Restor Dent. 2010? 22 (3): 158-167. doi:10.1111/j.1708-8240.2010.00330.x
- Mamoun JS, Napoletano D. Diagnosis and treatment of cracked teeth: an alternative paradigm. Eur J Dent. 2015? 9 (2): 293-303. doi: 10.4103/1305-7456.156840
