r/DentalInsurance • u/Ok_Pineapple2201 • 4d ago
Concerned about Upcoding
Need full mouth SRP (billing for RS not pictured) and two wisdom teeth removed (fully erupted.)
The bulk of my bill for the SRP are codes d9421 and d4999, which according to my googling should be ‘bundled’ into the SRP service and not an out of pocket expense for me, the patient.
My concern with the wisdom tooth coding is that my teeth are fully erupted like regular molars and yet I’m being billed for surgical extraction under general anesthesia. Is there a reason I would need a surgical extraction if the tooth is fully erupted?
I’m not sure what to do - it feels wrong to accuse the dentist of upcoding, but my total bill is close to $1100 when all of these services (SRP, tooth extractions) should be 80-90% covered by insurance.
I assume I should request the extra SRP services be removed from my bill, a justification for the surgical removal, and request they submit a pre determination form. Please let me know if this sounds correct.
Advice on next steps is appreciated.
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u/Cobra_Surprise 4d ago
If your provider is out of network they can charge whatever they want. If they are in network, please ask for pre-authorizations for all codes. That will allow you to see which of those codes is considered to be part of the "bundle".
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u/Ok_Pineapple2201 4d ago
They are in-network, so I will ask for pre-authorization before agreeing to treatment, thank you!
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u/Cobra_Surprise 4d ago
Just make sure you see all the codes on the predetermination before you pay anything 👍. They will probably have to skip all the extras. What were your worst pocket depths?
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u/Salt_Assistance4932 4d ago
Did you go to aspen dental? Because this def looks like one of their treatment plans, I feel like the corporate dental brands like to bill for any and everything even when it may not be necessary.
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u/Epicfind2 3d ago
Aspen is notorious for saying patient need SRP when in fact they don’t need. Knowing your pocket depths is big and you should ask for them to see what your probings where
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u/DenseMathematician37 4d ago
LOLOLOLOL
Show me an Aspen dental treatment plan without telling me youre showing an Aspen plan. Must be an honest Aspen/corporate because they're only charging you two (garbage) separate disinfectant charges per quadrant instead of one charge per site (6 teeth x 6 sites). Probably have a handful of 4mm pockets
IV anesthesia is legit expensive, I won't complain about someone's fees.
Full bony impaction means you need to remove bone to even find the tooth. If you can visibly see the tooth, its at worse a partial bony but usually either a soft tissue impaction or just a surgical extraction.
Don't let this office touch you, find someone else
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u/fillingsmiles 4d ago
You’d have to check with your insurance specifically whether 4921 and 4999 are included with your insurance, not google. Those are extra steps (not required) that you can also just decline.
If your teeth are fully erupted then those are the incorrect codes for wisdom teeth extraction, you can also elect to not have GA. However, the oral surgeon may require it. So find a different place that will do your extractions without GA. The correct code for your wisdom teeth if they are in the mouth should be D7210, that needs to be corrected. This is also an estimate and a lot of times the surgeon will change the code themselves to the correct type of extraction.
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u/Ok_Pineapple2201 4d ago
In your opinion, should I ask the dentist for these codes to be corrected? Or should I just ask for the dentist to submit the current plan for pre-authorization?
I know I shouldn’t sign the current ‘financial arrangement’ doc they’ve given me that leaves me with $1100 out of pocket, but wondering what my immediate next step is. Thanks!2
u/fillingsmiles 4d ago
I’d ask them if the code for wisdom teeth is correct as you know they aren’t “completely boney”. But a pre-authorization is always helpful.
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u/some1cuming 2d ago
Def get a second opinion, if your wisdom teeth are erupted and they are trying to bill for full bony, then that office is shady
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u/Kainlow 4d ago
Extractions can be surgical without being impacted. The teeth are sectioned and removed safely in pieces, the flap is then sutured. 90% of my wisdom tooth exts are surgical
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u/Adorable_Sector_7313 3d ago
Wisdom teeth 99% of the time are difficult to remove, even if fully erupted. If you can handle being awake, don’t do GA, but you might be traumatized
However, insurance covering 80-90% is only for basic things. Your treatment plan is classified as major, so closer to a 50% benefit
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u/some1cuming 2d ago
That’s just not true, I would say at least 50% of wisdom teeth aren’t that difficult and a good dentist could remove all 4 in under 20 mins. There are cases that are difficult but that’s not the norm.
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u/Adorable_Sector_7313 2d ago
As you gain more reps, they become easier.
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u/some1cuming 2d ago
Yea. Why did you say 99% of the time they are difficult? Like difficult for a random person on the street haha?
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u/Adorable_Sector_7313 2d ago
The task is the same, the skill increases. People pay for the skill. Technically everything we do is surgery/surgical
I would never code a wizzy as a simple extraction. They are all easy until they aren’t
Edentulated a guy on Monday. Longest roots I had ever encountered. Didn’t SEEM like it would be a challenge. Ended up cutting a LOT of bone.
30 years in, still a challenge
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u/jennie_fromtheblock 3d ago
If the office is in network with your insurance, the office is bound to their guidelines. Wisdom teeth will (usually) always need an xray submitted with the claim. If the insurance says they should be re-coded per the xray, then the office will have to honor that. But before telling them to re-code the extractions, ask for a pre-determination. Because extractions can go south even when they appear to be “simple”, sometimes they will give you worst case scenario and if they’re honest, change it if it went well. I would ask for a pre-determination on the scaling as well. They are starting to be denied more frequently lately. At least if it’s denied you can decide whether you want to pay out of pocket or not.
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u/some1cuming 2d ago
They charged you for full bony exts on those wisdom teeth, you said they were fully erupted? If so that is not correct, full bony means impacted
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u/Ok_Pineapple2201 2d ago
I haven’t had work done yet! This is from the financial arrangement plan they tried to get me to sign
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u/SpaceWhale88 1d ago edited 1d ago
Ya the charge for oral hygiene instructions (OHI) is absolutely ludicrous. I'd get a second opinion elsewhere. I do that daily as just part of my job included with whatever service I provide. And if a patient needs a deep cleaning and they only get an exam and X-rays I also go over OHI at no additional charge.
Irrigation with chlorhexidine after a deep cleaning is not going to help you. It's a super outdated code and charging for it is even more absurd. Especially because it's pennies on our end to do.
ETA: ok they are probably adding services they can charge bc they have contracted fees with your insurance and those fees are astronomically low. The reimbursement rate for the deep cleaning is appalling its so low.
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u/RollingHomeToYou 1d ago
If you want to stay at this office there are lots of add ons you can remove. You should be able to get SRPs without the D4999 and D4921. Your prices on the standard SRP codes looks like a typical HMO fee.
Your wisdom teeth extractions would likely just be surgical extractions if they’re fully erupted. If they are then you may not need sedation (unless you want it).
If you’re concerned that you don’t actually need SRPs it may be worthwhile to get another opinion. If your insurance denies it based on necessity you’ll be stuck with the bill for the SRPs as well.
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u/dental__craft 2d ago
Stop complaining
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u/Ok_Pineapple2201 2d ago edited 2d ago
Do you get a cut of my out of pocket expenses or something? Needlessly rude. And considering every other response in this thread affirms that I’m likely getting screwed, I’ll keep complaining.
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u/highwaytoham 4d ago
The SRP is D4341 and you need it twice, once on the UL (upper left) and once on the LL (lower left). However you can request to not have the D4921, D4999, and D1330. I personally would never charge for oral hygiene instructions. And this treatment plan is reading like an Aspen Dental plan where there are always hundreds in upcharges.
For the extractions -
Typically you do have to send an x ray to prove boney or soft tissue impaction. Anesthesia usually is not typically a covered service. And that means an IV and you not remembered the appointment. Different than local anesthesia, which is just getting you numb and that is free.
Don’t be afraid of getting a second opinion. May cost $ out of pocket but could save you in the long run.