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Periodontal claims submission: stop the denials!

Periodontal denials can stem from various factors, including coding errors, lack of documentation, and discrepancies in coverage policies

Team Wisdom

Insurance companies LOVE to deny periodontal claims: Don’t let them!

How many times have you asked yourself WHAT IN THE WORLD!? when periodontal claims come back denied, or downgraded, despite your best efforts? Well fear no more: We have some Wisdom for you!

Periodontal health is the cornerstone of a vibrant smile and overall well-being. Yet, despite the meticulous care and attention devoted to periodontal treatments, dental practices often encounter a frustrating hurdle: periodontal denials. In this blog, we delve into the complexities surrounding periodontal denials in dentistry, shedding light on common causes, prevention strategies, and tips for appealing denials.

The 3 most common causes of periodontal denials: 

  • Coding Errors: Incorrect coding, such as using a non-covered code or failing to specify the sites impacted properly can lead to denials. This issue could actually even halt the claim in your clearinghouse. 
  • Documentation Deficiencies: Inadequate documentation of the patient's periodontal condition, treatment plan, and post-operative care may result in claim denials
  • Coverage Limitations: Some insurance plans impose limitations on periodontal services, such as frequency and waiting period restrictions or pre-authorization requirements, leading to denials if not adhered to. 

Preventing Periodontal Denials:

  • Comprehensive Documentation: Ensure thorough documentation of periodontal assessments and clinical treatment notes, and acquire and attach all supporting documentation. We recommend using our clinical note template for scaling and root planing and our attachment cheat sheet to endure ALL information goes out with the initial claim. Make sure you have a recent Full Mouth Series on file for Scaling and Root Planing, Bitewings and/or Panoramic's will be much less likely to support the need for treatment. 
  • Accurate Coding: Use correct procedural codes and modifiers to accurately reflect the nature and severity of periodontal disease and treatment provided. For coding help there are books that can be purchased, including our favorite, published by the ADA, and we find this blog by RDH magazine helpful as well. 
  • Insurance Verification: Verify patient insurance coverage, including any limitations or pre-authorization requirements, before initiating periodontal treatments. You can use our Insurance Verification form in our free downloads to ensure your breakdowns are detailed and robust.

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