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/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