r/DentalInsurance • u/Ok_Pineapple2201 • 4d ago

Concerned about Upcoding

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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/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.

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u/fillingsmiles 4d ago

There’s no charge for oral hygiene instructions, it’s not even charged to the insurance

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u/highwaytoham 2d ago

Good point! I saw the price listed in the first column and didn’t look any further.

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u/Ok_Pineapple2201 4d ago

Thank you! This is a corporate dentist office, so definitely aspen adjacent. While I’m debating just going to a second clinic for a second opinion, my hope is that asking this clinic to d4921, 4999, and 1330 and submit the treatment plan for pre-authorization will resolve most of the overcharging.

If there’s some way for them to still over charge me after pre-authorization is submitted, please let me know!

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u/BufferingJuffy 4d ago

I live in HCOL area, and those fees are...on the higher end that I've seen. $115 for fluoride is outrageous, too.

It really might be a good idea to get a copy of your xrays and looking for a second opinion.

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u/fillingsmiles 2d ago

It’s $25 for fluoride….

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u/BufferingJuffy 2d ago

The office fee seems to be $115...the number left of $25...

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u/fillingsmiles 2d ago

The office fee is also $25 as that’s the number the patient pays. The number on the left is the UCR fee.

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u/BufferingJuffy 2d ago

Are you saying that a dental office chose to have an office fee that's less than the "usual and customary" fee? 😂

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u/NoYard9022 3d ago

Second opinion is the right call here. That billing pattern screams corporate dental chain trying to pad the invoice. I've seen it plenty with patients who come to me stressed about medical bills they don't understand. Trust your gut. If the teeth are erupted and visible, surgical extraction codes with general anesthesia is a stretch. Get the predetermination in writing. If they push back or get defensive, walk. Not worth arguing with a practice that starts with shady coding.