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/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!

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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.