Dental Insurance and Caries Management by Risk Assessment

There are many misconceptions within the public perception of dentistry surrounding dental insurance. The first and most important is the idea that “dental insurance” is “insurance” at all. When individuals purchase “insurance”, the purpose is primarily to protect themselves from an unlikely event or situation that would cost a significant amount of money—for example, the loss of a house in a fire, or being diagnosed with cancer requiring hundreds of thousands of dollars in medical procedures. This is true for most types of insurance as the insurance company collects small monthly premiums from a large number of participants and pays out loss-connected benefits according to their policies on statistically rare events or situations. This is the true definition of insurance. Fire insurance, life insurance, homeowner’s insurance, and even medical insurance all come under this definition.

A better definition of dental insurance is that it is more of a “dental benefit.” Dentistry is not a rare event, and according to the CDC, 85% of all adults experience dental decay. The cost of this care, while it is not inexpensive, does not accumulate to the levels of unexpected surgery and a long-term medical stay or replacing a home. Consequently, the classic model of insurance doesn’t work well in dentistry. For that reason, in the 1960s, dental insurance was invented as an employer-sponsored benefit to assist employees in offsetting the costs of regular dental maintenance. But because so many individuals have dental needs, in order to offer the dental insurance, caps were put in place to limit the benefit to $1,000–$2,000 per year in most cases.

Due to this cap, most policies that are purchased by individuals, employers, and employees primarily include coverage for regular cleaning visits and restorative work like fillings and crowns. Although policies do exist with coverage for preventive therapies and other necessary dental procedures, often, dental customers choose insurance policies with a focus on restorative and regular checkup benefits based on a treatment model of care, not a wellness model.

The next most prominent misconception regarding dental insurance occurs when patients believe that their dental benefit covers all of their necessary oral health care needs, and anything that is not covered by their benefit is not necessary to maintain their oral health. This is often a real frustration for both dental practitioners and patients. For example, a patient presents with 4 new cavities and periodontal (gum) disease and has caries risk factors and a high biofilm challenge (caries infection). In order to adequately treat the patient and make strides toward health, all areas of decay need to be removed and filled, periodontal therapy performed, and antibacterial caries therapy started. But the patient only has enough dental benefits to cover 2 of the 4 necessary fillings and does not want to move forward with any treatment that is not covered by their benefit.

While “out of pocket” financial implications of dental and medical treatment are always a consideration, and for some, the costs are an insurmountable obstacle, untreated dental disease and untreated oral infections like periodontal disease and caries are extremely unlikely to “heal” on their own. Patients who do not take immediate action to repair and treat the disease, or allow their dental benefits to guide their treatment plan, will face amplified progression of the disease and increased costs. For some patients, this is a frustrating downward spiral, and eventually, they reach a “point of no return” and opt to have their teeth removed. This entire book is designed to help stop that process.

The truth is that dental insurance is a product, and what type of procedures covered and the limitations of coverage are bundled into different “policies” or packages, which are then sold to employers or individuals. The dental insurance policies are designed to do three important things: The insurance plan must fit the insurance company’s financial needs for profitability. The plan must meet the annual policy price points expected by employers, employees, and individuals. And finally, the plan must provide adequate procedure compensation for the provider (dental practice).

Currently, multiple insurance companies sell policies with coverage for dental procedure codes associated with CAMBRA, including D0425 for caries susceptibility testing (CariScreen), D1206 for therapeutic applications of fluoride varnish for moderate- or high-caries-risk patients, D1310 for nutritional counseling for the control of dental disease, and D9630 for other drugs, medicaments, or fluoride dispensed by the office for at-home use (see chart of all codes). While this list is not all-inclusive and many other CAMBRA procedure codes exist, many patients believe that if their insurance policy doesn’t cover caries susceptibility testing or drugs and medicaments dispensed by the practice for the control of dental disease, the recommendations being made are not necessary for health. This is simply not true.

Codes and Coverage

This is a guide about coding. It’s important to understand that coding and coverage are not the same. The existence of a code does not mean a patient has coverage under a policy. Yet without a code, no coverage could be offered. This is often where confusion lies. Codes and coverage are related but not the same. Codes serve as the most accurate documentation and possible coverage under a policy. Dental professionals are obligated to use the most accurate code available. However, accurate coding does not guarantee coverage under a particular policy.

Dental/Medical Necessity

CDT codes are risk- and diagnosis-based, not product-based. Documenting dental/medical necessity in Box 35 Remarks can optimize coverage under a policy. Below are the following codes that best apply when implementing the CariFree program.

Steps 1, 2, 3: Assess, Test, Diagnose
Caries Risk Assessment (CRA) Form

CariFree CRA form documents accurate risk assessment. This information is part of the dental/medical necessity.

These can be considered modifier codes to support WHY for other care. There may/may not be coverage for these codes but should be submitted in conjunction with other codes.

  • D0601 caries risk assessment and documentation, with a finding of low risk
  • D0602 caries risk assessment and documentation, with a finding of moderate risk
  • D0603 caries risk assessment and documentation, with a finding of high risk
    • Description for all 3 codes: Using recognized assessment tools.
CariScreen Test (if applicable)

A numeric score provides specific documentation for patient, practice and 3rd-party payers. This information is part of the dental/medical necessity.

  • D0425 caries susceptibility tests
    • Not to be used for carious dentin staining
Evaluation Codes

Diagnosis and treatment planning is a required part of all evaluation codes.

risk factors 1

General description for all evaluation codes: “…the evaluation, which includes diagnosis and treatment planning….” Legal precedence-if not documented, not done.

  • D0120 periodic oral evaluation – established patient
    • An evaluation performed on a patient of record to determine any changes in the patient’s dental and medical health status since a previous comprehensive or periodic evaluation. This includes an oral cancer evaluation and periodontal screening where indicated and may require interpretation of information acquired through additional diagnostic procedures. Report additional diagnostic procedures separately.
  • D0145 oral evaluation for a patient under three years of age and counseling with primary caregiver
    • Diagnostic services performed for a child under the age of three, preferably within the first six months of the eruption of the first primary tooth, including recording the oral and physical health history, evaluation of caries susceptibility, development of an appropriate preventive oral health regimen and communication with and counseling of the child’s parent, legal guardian and/or primary caregiver.
  • D0150 comprehensive oral evaluation – new or established patient
    • Used by a general dentist and/or a specialist when evaluating a patient comprehensively. This applies to new patients; established patients who have had a significant change in health conditions or other unusual circumstances, by report, or established patients who have been absent from active treatment for three or more years. It is a thorough evaluation and recording of the extra oral and intraoral hard and soft tissues. It may require interpretation of information acquired through additional diagnostic procedures. Additional diagnostic procedures should be reported separately. This includes an evaluation for oral cancer where indicated, the evaluation and recording of the patient’s dental and medical history and a general health assessment. It may include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, existing prostheses, occlusal relationships, periodontal conditions(including periodontal screening and/or charting), hard and soft tissue anomalies, etc.
  • D0171 re-evaluation – post-operative office visit
  • D0190 screening of a patient
    • A screening, including state or federally mandated screenings, to determine an individual’s need to be seen by a dentist for diagnosis.
  • D0191 assessment of a patient
    • A limited clinical inspection that is performed to identify possible signs of oral or systemic disease, malformation, or injury, and the potential need for referral for diagnosis and treatment
Step 4, 5: Recommend, Reassess
Codes for In-office Treatment: CAMBRA
  • D1206 topical application of fluoride varnish
  • D1310 nutritional counseling for control of dental disease
    • Counseling on food selection and dietary habits as a part of treatment and control of periodontal disease and caries.
  • D1320 tobacco counseling for the control and prevention of oral disease
    • Tobacco prevention and cessation services reduce patient risks of developing tobacco-related oral diseases and conditions and improves prognosis for certain dental therapies.
  • D1351 sealant – per tooth
    • Mechanically and/or chemically prepared enamel surface sealed to prevent decay.
  • D1352 preventive resin restoration in a moderate to high caries risk patient – permanent tooth
    • 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.
  • D1353 sealant repair – per tooth
  • D2940 protective restoration
    • Direct placement of a restorative material to protect tooth and/or tissue form. This procedure may be used to relieve pain, promote healing, or prevent further deterioration. Not to be used for endodontic access closure, or as a base or liner under a restoration.
  • D2941 interim therapeutic restoration – primary dentition
    • Placement of an adhesive restorative material following caries debridement by hand or other method for the management of early childhood caries. Not considered a definitive restoration.
  • D9910 application of desensitizing medicament
    • Includes in-office treatment for root sensitivity. Typically reported on a “per visit” basis for application of topical fluoride. This code is not to be used for bases, liners or adhesives used under restorations.
  • D9911 application of desensitizing resin for cervical and/or root surface, per tooth
    • Typically reported on a “per tooth” basis for application of adhesive resins. This code is not to be used for bases, liners, or adhesives used under restorations.
Codes for Patient Counseling and Home Therapy Recommendations
  • D1330 oral hygiene instructions
    • This may include instructions for home care. Examples include tooth brushing technique, flossing, use of special oral hygiene aids.
  • D1999 unspecified preventive procedure, by report
    • Used for procedure that is not adequately described by another CDT Code. Describe procedure.
  • D9630 drugs or medicaments dispensed in the office for home use
    • Includes, but is not limited to oral antibiotics, oral analgesics, and topical fluoride; does not include writing prescriptions.
  • D9920 behavior management, by report
    • May be reported in addition to treatment provided. Should be reported in 15-minute increments.
  • D9993 dental case management – motivational interviewing
    • Patient-centered, personalized counseling using methods such as Motivational Interviewing (MI) to identify and modify behaviors interfering with positive oral health outcomes. This is a separate service from traditional nutritional or tobacco counseling.
  • D9994 dental case management – patient education to improve oral health literacy
    • Individual, customized communication of information to assist the patient in making appropriate health decisions designed to improve oral health literacy, explained in a manner acknowledging economic circumstances and different cultural beliefs, values, attitudes, traditions and language preferences, and adopting information and services to these differences, which requires the expenditure of time and resources beyond that of an oral evaluation or case presentation.
Twitter-Style Dental/Medical Necessity

Dental/medical necessity is the reason why a test, a procedure or an instruction is given. Twitter-Style writing is to cut unnecessary words and allows documentation to fit in Box 35 Remarks on claim forms.

Sample Case Submission with Twitter-Style Dental/Medical Necessity for CAMBRA

Johnny is a 6 year old boy who is not a dental patient of record. He was screened in a school-based program. He has had many ear infections. He lives in a low socioeconomic community. His mom works 2 jobs, 16 hours/day, and isn’t able to afford quality nutritious food, so consequently, Johnny has poor unsupervised dietary habits. His mouth shows heavy plaque, tissue bleeding, white spot lesions, and a high level of active cavitated lesions.

The dental/medical narrative is a concise 156 characters as follows:


(Note: Sample only-does not reflect complete treatment plan)

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