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11
Legal Issues Involving Restorations
Tom Michael, DDS (East Wenatchee, WA)
Carol Sue Janes, JD (Seattle, WA)
© Copyright 2006 Bennett Bigelow & Leedom, P.S.
22
When Is It a “Restoration”?
Dr. Michael providing MID treatment• early detection• microburs• flowable composite restorations• charted on treatment plan and notes
33
When Is It a “Restoration”?Medicaid Audit alleged overpayment assuming:• That restorations were sealants
– lack of pre-operative x-ray evid of decay– some treatment w/o anesthesia– flowable composite “inappropriate restorative
material”– speed of restorations (no rubber dam) – some symmetry of restorations
• That restorations were not done– no post-operative x-ray evid of restoration– post-op visual clinical exam of some patients
44
Patient SB15 OL, OB (pre-operative BW)
55
Patient SB15 OL, OB
66
Patient SB15 OL, OB
77
CDT Codes for Restorations
When is it a restoration (vs. a sealant)?
Must be into the dentinResin-based composite – one surface, posterior
Used to restore a carious lesion into the dentin or a deeply eroded area into the dentin. Not a preventive procedure.
- ADA CDT manual
(CDT-4 D2391)
(CDT-3 D2381)
88
Into dentin or not?
99
CDT Codes for Restorations
What surfaces are involved in restoration?
- the number of surfaces of the restoration is defined by the number of surfaces that the restoration “extends to”
- ADA CDT manual (CDT-2, -3, and -4)(D2000-
D2999)
1010
Which surfaces do you bill?
1111
CDT Codes for Restorations
What surfaces do you bill?
The ones that you do? Or less?
How do I report two separate 2 surface restorations on the same tooth?
Reporting these restorations as a MO and a DO is appropriate.
- ADA CDT manual
(CDT-4 p. 91)
1212
Patient SB15 OL, OB
1313
Which surfaces do you bill? How many restorations?
1414
Which surfaces do you bill?
1515
The “Perfect Storm”
Medicaid Audit– alleges overpayment
Dental Board– Medicaid refers allegations to Board
Medicaid Fraud– Medicaid refers to criminal fraud investigators
Third-Party Payors– Terminate status as provider
1616
Dental Board Findings
• lack of pre-op x-ray evid of interprox decay
• lack of post-op x-ray evid of interprox restorations
• lack of post-op evid (in clinical exam) of all surfaces restored
• use of amalgam billing codes
1717
Discussion Points
• How to treat
– Risks: “overtreatment”/“undertreatment”
– “Dentally necessary”
– Patient consent
1818
Range of practices for pit and fissure decay:
• Do nothing - “Watch”• Sealant with no preparation of tooth• Sealant with minimal preparation of tooth• Sealant with preparation in enamel only, but to
point where all margins are in non-stained, prismatic enamel
• Minimally invasive preparation removing all decay into dentin
• Traditional GV Black preparation
1919
Discussion Points, cont’d
• How to bill
– Knowing the CDT/Billing Instructions/laws
– Read your contract
– Risks
2020
Discussion Points, cont’d• Documentation!
– Not just x-rays/charts– Pre-op– Post-op
• Benefits of Documentation– Legal– Insurance– Patient education and confidence– Staff education and confidence– Enhanced quality control– Professional satisfaction
2121
The Value of Documentation
2222
Concluding Thoughts
• Know the risks
• Practice preventive dentistry
• Legal battles are real and painful