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Legal Issues Involving Restorations

Tom Michael, DDS (East Wenatchee, WA)

Carol Sue Janes, JD (Seattle, WA)

© Copyright 2006 Bennett Bigelow & Leedom, P.S.

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When Is It a “Restoration”?

Dr. Michael providing MID treatment• early detection• microburs• flowable composite restorations• charted on treatment plan and notes

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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

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Patient SB15 OL, OB (pre-operative BW)

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Patient SB15 OL, OB

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Patient SB15 OL, OB

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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)

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Into dentin or not?

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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)

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Which surfaces do you bill?

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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)

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Patient SB15 OL, OB

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Which surfaces do you bill? How many restorations?

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Which surfaces do you bill?

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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

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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

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Discussion Points

• How to treat

– Risks: “overtreatment”/“undertreatment”

– “Dentally necessary”

– Patient consent

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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

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Discussion Points, cont’d

• How to bill

– Knowing the CDT/Billing Instructions/laws

– Read your contract

– Risks

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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

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The Value of Documentation

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Concluding Thoughts

• Know the risks

• Practice preventive dentistry

• Legal battles are real and painful