Insurance Coding for CAMBRA Practices

Switching your dental practice to a CAMBRA (Caries Management by Risk Assessment) focused practice is more than just a change in treatment. Because the daily activity of your practice and how you interact with your patients changes, the way you bill for those interactions will likely need to shift with the focus of your practice. This is not purely self-interested; it is in the best interest of your patients as well. Patients want to use their dental insurance to help control the costs of care, and you want your patients to continue receiving the treatment they need for optimal health. If you understand proper coding for CAMBRA care, you assist your patients by providing an accurate documentation of care for insurance reimbursement.

CDT codes provide a way to group risks and diagnoses. Of course, you will need to use the most accurate codes available, although using the most accurate code does not guarantee that the care will be covered. Coverage depends on the insurance policy, not exclusively on the medical determination of the patient’s specific needs. Documenting medical necessity is the best way to make a case for coverage. Documenting necessity in the small box 35 provided for remarks on the claim form is something of an art form. Twitter-style writing is an art form to cultivate when writing up claims.

When writing up your claim forms, consider following the natural steps of a CAMBRA visit. Code first for steps 1, 2, and 3: Asses, Test, Diagnose. The Caries Risk Assessment Form is part of your documentation here, as is the CariScreen test. Follow up with codes related to steps 4 and 5, Recommend and Reassess.  This will cover in-office treatments like fluoride varnish application, sealants, and restorations. You can also code for time you spend counseling the patient on home care and at home treatment recommendations.

Please feel free to download our Insurance Reimbursement Guide for your convenience. It gives specific examples of appropriate codes for CAMBRA treatment.

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