The Dental Billing Podcast
Dental billing is not data entry. It's the difference between a practice that collects what it earned and one that writes it off and calls it the cost of doing business.
The Dental Billing Podcast is hosted by Ericka Aguilar and Jen Lyman, RDH. Ericka has been a dental biller since 1998 and has taught billing in 31 states and Mexico. Jen came out of the operatory and now runs Lyman Revenue Solutions, handling both dental and medical billing. One of us knows exactly what the carrier is going to do with your claim. The other one knows what actually happened in that chair. You get both.
Every week we break down denials, appeals, coding, and the carrier behavior nobody warns you about, in plain language, with real sources. We teach the law before the codes, because a code doesn't win an appeal. Knowing what that carrier is legally required to do wins the appeal.
If you've ever been told you're "just the biller," this show is for you. Downloads in 114 countries and counting. Bring your coffee and your worst denial.
The Dental Billing Podcast
Protocol Vs Standard Of Care In Dental X Rays with Jen Lyman, RDH
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Someone on the internet said it’s “no longer protocol” to take x-rays at recall, and that one word is where the real danger starts. Radiographs are not a habit we do on a timer. They’re part of a provider’s standard of care, and that standard of care is a clinical decision the treating doctor owns, documents, and can defend.
We walk through the practical difference between protocol and standard of care, then get specific about what the ADA and FDA patient selection guidance actually says (and what it does not say). We talk ALARA, why fixed schedules can be just as problematic as blanket “never” rules, and why the order matters every time: clinical decision first, money second. If you’re seeing more payer pushback and “clinical justification” requests, this conversation gives you language that protects both patients and the practice.
Then we get into the part billers and office managers can use immediately: what not to write in the chart or claim remarks, how fraud vs abuse is evaluated, and how an undocumented service can look identical to an unnecessary one during an audit. You’ll hear ready-to-copy narrative examples that include indication, findings, diagnosis, and disposition, plus a clear explanation of diagnosis coding, ICD-10, and how the ADA dental claim form fields (including diagnosis pointers) help a payer understand the story of the tooth.
If you want fewer denials and stronger appeals without letting insurance steer treatment, press play, share it with your clinical team, and bring your ugliest examples. Subscribe, share with a teammate, and leave a review so more dental billers can find this and document with confidence.
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https://calendly.com/ericka-dentalbillingdoneright/30min
Email Ericka:
ericka@dentalbillingdoneright.com
Email Jen:
jen@dentalbillingdoneright.com
Why “Protocol” Is The Problem
SPEAKER_00Hello, dental billers. This is Jen Lyman, dental hygienist, and one of the co-hosts on the dental billing podcast. I want to start with the exact sentence that set this episode off because a lot of you have heard some version of it in your own office. Somebody said out loud on the internet that is no longer protocol to take x-rays at recall visits. Period, full stop, no caveats. And here's why that bothered me. And it's not the part that you'd actually expect. It's not that I think every patient needs bite wings every 12 months, no matter what. That's not my position either. What bothered me was the word protocol. Radiographs are not protocol. They have never been protocol. They are the standard of care to take care of the patients. And those two words mean completely different things. One is a habit, the other is a defensible clinical decision the treating doctor owns. And when a biller who has never held a sensor, never taken a health history, never looked in the patient's mouth, starts telling offices what is and isn't protocol, I believe that we've crossed a line. Not because they're a bad person or anything like that, but because she answered a clinical question with a billing answer. And that is backwards. So today we're fixing that all the way down to the words you type into the notes. So let's get started. Again, my name is Jen Lyman. I'm a dental hygienist turned biller and one of your co-hosts here on the dental billing podcast. Before I ever touched a claim, I spent years with my hands in people's mouths. I've placed the sensors, I've had the patient gag, hold the trash can for them. I've watched lesions, I flagged 18 months ago turn into a root canal because somebody decided the interval could stretch out. I have seen Perio progress to where it was no longer recognizable, no longer treatable because the patient couldn't afford treatment at the time. And now they put it off for so long, and we took a follow-up x-ray years later and now need full extractions. I also own a billing company now, and I spend my days in denials and appeals. But I came up clinical and this topic needs a clinician's voice on it. And that's exactly why I want to talk to you about that today. So the whole episode is from that side of the chair. Where we're going. So protocol versus standard of care. What the ADA and the FDA actually say, because people quote them constantly and almost nobody actually reads them. So I want to talk about how your practice builds its own standard of care in writing based on the doctor's preferences on how we can best treat our patients and keep them healthy and actually diagnose the things that you need to diagnose. That's the fraud and compliance piece. Keeps us dispensable and we're able to justify why we are doing what we're doing. So the two comments that took over my thread was one of them was from a dentist, and it's the funniest and darkest thing anybody said all week on my social media by far. The actual verbiage, real sentences you can put in a note tomorrow. And we're going to also talk about diagnosis coding, which is where all of this ends up and where we need to bring it back to. So stick around because that last piece is the exact topic of the webinar that Erica and I are running on September 1st. You'll definitely want to sign up
Defining Protocol Vs Standard Of Care
SPEAKER_00for that. So let's define our terms because a lot of confusion in dentistry comes from using two words interchangeably that are not actually interchangeable. This happens a lot between the back and the front. So a protocol is a routine, a fixed sequence. This, then that, then this, same order every time, regardless of who's in the chair. Protocol is what you do because it's what you do. This is what the doctor has assigned. Let's take a new patient, for example. You would not start off a new patient getting their insurance information, right? You would get their demographic information, then the insurance information, then talk about previous offices. That's protocol. There's steps, systems, and processes that do not change, but typically they're more for when we are doing things within the office, not taking care of the patient. Standard of care is very different. It's what a reasonably prudent provider with training and credentials in similar circumstances would do for this specific patient. It's not a rule book that you download. It's a judgment call the treating doctor makes and then documents. So there's a practical difference here. Protocol says we take four bite wings on every adult every 12 months. Standard of care says this doctor requires current diagnostic imaging before diagnosing interproximal caries, evaluating bone levels, or prepping a tooth for a restoration. And the interval for this patient is set by her risk, their history, and what I see in their mouth today. Do you see how those are so different? One of those you can defend, the other one you cannot at all. And here's the clinical version of why that matters, because I've lived it. As the hygienist, when you're the one who sees this patient every six months for years, you know when their home care falls apart. You know when they start a new medication, you know when she's had two new fillings since last spring or an extraction randomly at a specialist's office. And maybe they want an implant now. You know her their whole mouth is drier than it used to be. You know they're bleeding more than they used to be. None of that is on a schedule and all of it changes the answer. And it could be everything from systematic changes, systemic changes to home care to stress levels, for there's so many different reasons why that can change. So a protocol can't hold any of that. The standard of care can, because it's built to take clinical judgment as an input, which is the whole entire reason that I made the original video on TikTok. The standard of care belongs to the doctor, not to the insurance company, not to guidelines, me as a biller, and definitely not to some stranger on TikTok. So what I want to really get home here is that every practice needs to decide what they require in order to treat a patient safely. And there needs to be a reason for that. And that is the provider standard of care. And everybody in the office needs to be on the same page about that, including us as billers. So once that is that is established, everything else, coverage, frequency limitations, patient out of pocket, whether the plan pays a dime on x-rays, or if it's all a completely separate conversation and out of pocket. All of it is a separate conversation that happens after the clinical decision, not before it. So our insurance verification needs to be accurate so that when things change, we are able to accurately code and extract the documentation in order to bill. And this all came about from the principal requirements now. The principal requirements now say that you can no longer take PAs. Okay, watch my verbiage here. You can quote unquote no longer take PAs without giving clinical justification. So notice that I said after the clinical decision is when we figure out how much the patient owes. That order matters more than anything else, I'm going to say today. Clinical decision before money. And I know as billers, a lot of times we want to talk about money before we want to let the provider make the clinical decision. But I'm encouraging you otherwise. Let them make their clinical judgment and diagnose what they need to diagnose and get the diagnostic imaging. Then we need to come alongside them and support them in that decision and give the patient the information about their financial decisions. So I want to be fair here because I'd rather be right than loud. So the person in that video did not invent her own opinion out of thin air. In January of this year, the ADA and the American Academy of Oral and Maxillofacial Radiology published new recommendations on patient selection for dental radiography and cone beam CT, which we're seeing a lot more of recently. First major update in over a decade. First one to cover both. So what it says, in essence, is that imaging should be ordered when it's clinically necessary, after you've reviewed the medical and dental history, reviewed the prior images, and completed a clinical exam. Which doesn't make sense to me because a clinical exam needs to come with the x-rays. So we do need to know what we're getting into, but those other things are better first. So what it says in essence is that imaging
Clinical Judgment Before Money
SPEAKER_00should be ordered when it's clinically necessary, after you've reviewed the medical and dental history, reviewed prior imaging, and you've done a quick exam of the patient to see if anything has changed in your clinical judgment. Frequency driven by clinical findings and treatment response rather than a fixed schedule. Imaging is an adjunct to diagnosis, not a screening tool. So if you want to argue that reflexively bite wing every patient every 12 months, taking three PAs without looking at anything is not best practice, that case exists. As a clinician, I'd agree with a lot of it. Radiation isn't free, and I don't want to expose anybody I don't need to expose. This is why we practice Alara. But that's not what that original poster online said. She said it's no longer protocol to take radiographs at recall. She took a nuanced clinical recommendation and turned it into a blanket rule covering all the providers, which is in essence an error on her part. She replaced always with never, and both of those are protocol thinking, not the standard of care. I took a direct quote off the FDA's own page on the ADA FDA patient selection guidance. These recommendations, quote, are intended to serve as a resource for the practitioner and are not intended to be a standard of care, requirements or regulations, unquote. Regulations and protocol. Sound familiar? So the guidance itself says it that it's not the standard of care, that the doctor needs to determine that on their own. So if your standard of care is a flat rule with no clinical thinking behind it, obviously those things are going to get denied. And yet we come back surprised and trying to fight something that we didn't even give them a reason for in the beginning. So I really want to talk about things that we can add to our clinical notes to give justification for x-rays. And as a biller, to say, this is why we took them. This is the justification for that. And I want to talk about compliance, fraud, and what actually gets you in trouble when it comes to radiographs. So fraud, the way regulators think about it, is knowingly submitting a claim you know to be false. Abuse is a pattern that results in payment you weren't entitled to, even without the intent. And under the False Claims Act, reckless disregard and deliberate ignorance count. So apply that to radiographs. Three ways offices can get hurt. First is billing for images that weren't taken, obviously, weren't diagnostic, and retakes were billed as new. Obvious. So I'm gonna move on from that one. Second, nobody sees this one coming, honestly. When the chart cannot explain why this service was done, there's no diagnosis to prove that that service needed to be done. In an audit, an undocumented service and an unnecessary service look identical to them. So your defense is not your memory and you can't defense your note. So they're gonna fine you on that. The third one is when the documented reason for a service is the insurance company. So this is another one that I got on my my TikTok post recently. Another lady said, Well, why can't we just put that insurance will deny it if we don't take this x-ray? Is that what is best for the patient? Did we need that x-ray? And why did we take it? What was diagnosed? What was done about it? What was documented? So the first one that somebody wrote basically just said, Why can't we just put because insurance won't cover the crown without x-rays? It's true, right? So why can't we say that? I want to explain why from the clinical side of things to you guys as billers, office managers, and dental practice owners. That sentence answers a question nobody asked. And in the process, it answers a question that you really did not want to answer. The payer's not asking why you took the radiograph, they're asking what it showed. Very different questions. So when you write insurance won't cover the crown without an x-ray, you've told the reviewer already that the reason the image exists is for the reviewer. You've documented in your own record that the driver of the service was reimbursement, also known as billing for benefit. Something that Erica and I have been against from the very beginning. So I encourage you to not do that and to think about a clinical reason that existed before the plan even did. If we take insurance off the table, why did we take this x-ray for the patient? If you seat a crown and you need to take a bite wing to make sure that the margins are smooth and they're sealed, that's your reason. It's not because insurance needs a crown seat x-ray. That's not the reason. So that's a trap that I need you to step back from and really, really
What ADA And FDA Guidance Actually Says
SPEAKER_00think about. The insurance is never the reason for an x-ray. The insurance company is the audience. Yeah, sure. But the reason is always clinical and it needs to exist before you even pull up the breakdown. So insurance second, clinical decision making first. Now I want to talk about what we actually need to say on our claim forms for companies like Principal who are asking, why did you take this? So I wanted to want to get into that for you. And I'll try to go slow so that you guys can save, download, share this episode with your clinical team so that you guys can all be on the same page and update your templates. Okay, I'm gonna try to go slow, but I also need to keep this episode under a certain amount of time. Okay. Recall bite wings, patient with active risk factors. Here's what your clinical documentation, an example of what this could say. Patient presents for periodic evaluation, carries risk assessed as high. Two restorations were placed within the last 12 months. Patient reports dry mouth, secondary to current medications reviewed during the health history, and visible plaque accumulation on posterior interproximal surfaces. Four horizontal bite wings ordered per practice standard of care for high carries risk, patient to evaluate interproximal surfaces not accessible to visual or tactile examination. Findings include incipient interproximal radial lucencies, distal of tooth number three, confined to enamel, diagnosis. If you guys come to our webinar, you will understand this more, is K02.61, dental carries on smooth surface limited to the enamel. Disposition, monitor with fluoride varnish, and reevaluate at next interval. Do you notice what that does? It tells you why the patient was imaged, what we found, what it is, and what happens next. So a reviewer who has never met this patient understands the entire encounter and why we're doing what we're doing. And you want to make sure that you document your negative findings to clinicians. So people skip that constantly. They say no interproximal carries, existing restorations intact, bone levels within normal. People skip that constantly. Examples like no interproximal carries detected, existing restorations intact, bone levels within normal limits, no incipient carries is a finding. That is an actual finding. And a radiograph that rules something out still did clinical work. So we need to make sure that we say so. Next example is for a PA. Patient presents with spontaneous lingering thermal sensitivity in the lower right quadrant, keeping her up at night. Four days duration, PA of number 30 order to evaluate PA status and rule out any pathology at the apex. Findings, deep existing restoration, approximating pulp chamber, widening periodontal ligament space at apex, pulp testing consistent with irreversible pulpitis. Diagnosis, again, K04.02, irreversible pulpitis, disposition, root canal therapy recommended and scheduled. Do you see the progression in all of these? There will be a theme as we go through these. PA ordered for number 19 prior to prep to assess remaining tooth structure, evaluate depth of existing restoration relative to the pulp, assess PA status, and evaluate crown to root ratio and bone support to determine restorability and long-term prognosis. Findings are restoration extends to within one millimeter of pulp chamber, no PA radiolucency, adequate bone support, crown to root ratio favorable. Diagnosis would be a K08.531, fractured dental restorative material with loss of material. The disposition for this of the treatment is tooth restorable, full coverage crown indicated. Patient advised a possible need for endotherapy given proximity of restoration to pulp. We are giving them an undeniable reason as to why we need this x-ray prior to the crown. And it supports the crown 10 times better than an insurance requires an X-ray ever
Fraud Risks And Note Traps
SPEAKER_00could, because it actually tells the reviewer the tooth is restorable and why full coverage is indicated. This also helps if you if your office since pre-offs or later when we send the claim, we're able to look back at the LOE or the POE and be able to see what the diagnosis was for that tooth and why we took the x-ray and when we did. Now, because I'm a hygienist, of course I have to get into scaling and root planning. So this one, I would say comp perioevaluation completed, and that's the D0180 for those of you wondering. Full mouth probing, generalized 5 to 7 millimeter pocket depths and posterior sextants, bleeding on probing at 68% of sites, generalized subdigital calc detected by exploration, radiograph evidence on generalized horizontal bone loss 30 to 40%, class one frication involvement T3 and 14, clinical attachment loss consistent with generalized severe chronic periodontitis. Diagnosis would be K05.323, chronic period generalized severe. Our treatment now is indicated as scaling and root planning for quadrants with periodonal re-evaluation from four to six weeks. This could also be for your post-op bite wings after SRP. They could be clinically indicated because of this. It's also a great thing. That last note that I just mentioned is great for an FMX to prove an FMX is needed for scaling and root planning to be able to see bone levels. Not because they're just the new patient. That's not a good enough reason. All right. So one last thing in this section where the narrative lives matters. Your primary documentation is in the clinical note in the chart, and the doctor owns that as their standard of care. What you put in the remarks. Field billers on a claim is the summary of what's already in the record, never a replacement for it. And it should never say anything the chart doesn't already say. So the claim narrative is a window into the chart giving standard of care. It's not the chart. I want you to notice something about every example that I read. Everyone had a diagnosis in it. That wasn't an accident at all. And it's really where I want to hone in on by the end of this episode for you, because this is the biggest gap in dental billing right now. And it's something that Erica and I preach every single day all across our social media, when we talk on stage, when we mentor new billers, even when we go into an office, we are honing in on diagnosis codes and how you can tell a story about a tooth and about a service based on the diagnosis code. So dentistry uses obviously CDT codes, but CDT tells the payer what you did. It does not tell them what was wrong or why. The second part is that ICD 10 coding. And it's a language the rest of healthcare has been speaking for for years. While we mostly haven't, there is highly trained medical billers and coders, and they go to school for these things to learn how diagnosis codes can back up CPT codes. So we need to learn as best we can how to use these diagnosis codes on our claim form because, like I always joke as a hygienist, that somehow it is unbeknownst to medical insurance that the mouth is connected to the body. So here's the honest state on that. On a standard dental claim, ICD 10 is not required for every submission. I want to be very honest about that. It is not a requirement for every payer. The ADA claim form, however, has field number
Verbatim Note Examples That Defend Imaging
SPEAKER_0034, box 34, your diagnosis code list qualifier, where you would enter A B indicating that you are using the ICD 10 codes, not ICD 9 or a prior version. Then 34A holds the codes up to four diagnosis, primary first at letter A, and so on, B C D. And on each service line, box 29A is your diagnosis pointer. If you guys have a chance and you're this is completely new information to you, I encourage you to go look at the ADA 2024 claim form because you'll see it there and you'll know exactly what we're talking about after this episode. So box 29A is your diagnosis pointer, the letter that connects the procedure to that diagnosis. So let's say that you are billing out D4346, scaling in the presence of gingivitis, you would want to put in ICD 10 in your code list qualifier. And then in box 29A for D4346, we're going to pair it with the gingivitis code K05.10, which is gingivitis, plaque induced. Do you see how those connect the two? It connects this is why we're doing something, and this is what was done because of this diagnosis. So the ADA's own instructions say use those fields when the diagnosis may affect adjudication, or when your state or payer contract requires it. So not everybody is yet, but I want you to reframe that. So whether the code goes in the box or not, the diagnosis has to exist in the chart, in the clinical chart providers, because the diagnosis is what makes the service defensible in court or with an insurance company or anything like that. It needs to be in the clinical documentation. Field 34 is optional a lot of the time. However, having a reason never is. And that's what I wanted to get across on my social media. We should always have a reason for what we're doing. And if we don't, we shouldn't be doing it as providers. And billers, same thing. We need to be able to talk to our providers and not tell them that you can't do something because insurance won't allow it or because you have to prove it now to insurance. Instead, let's think about a better way to be more collaborative and strategic because it trains the doctor to stop listening to us if we just instantly tell them they can't do something, even though they want to take care of the patient and they know that this service would help them. So I want to encourage you to not be the biller who says no, but start being the biller who asks for the reason and translates it into something a payer can understand. We are the bridge between our providers and the insurance company. So it is our job to take a clinical decision and turn it into a diagnosis, a code, and a narrative, never to make the clinical decision. I have heard billers say you can't do that. That is one of the most annoying things to hear as a provider because we are the clinicians making these clinical decisions for our patients based on what they need. It is not based on insurance. I don't care what insurance they have. I know you do as the biller. And I'm going to be sympathetic to that and I'm going to help you support that claim the best way that I know how by my clinical notes. I won't still do the service. I'll document for it. I will code. I will give you everything you possibly need to get that covered. But non-covered is a financial conversation. It's never a clinical one. So we need to get away from the verbiage that states you cannot take something because it's not covered. We need to stop billing for benefit. We need to document for what we're doing and back that up with diagnosis for what we're doing and explaining to the payer what that is. So I could talk all night about diagnosis codes. I won't do that. We have an entire webinar coming up on September 1st. I hope this episode was helpful trying to peel back the layers that come with a dental claim and how we can best support our providers, get things paid, yes, but also explain to the payers and stay defensible when it comes to radiographs, especially. I want to encourage you to look at the ADA claim form, look at that field 34, 34A,
Diagnosis Codes And The ADA Claim Form
SPEAKER_00and the pointers so that you can understand all of that. If you took notes during the verbiage section, the webinar is the rest of it entirely. And that will give you the full sentences and the codes that go along with them and how we can use those. So the registration link will be below in the show notes. It's also in my bio at TikTok and Instagram at hygiene unlocked. It's also at the Dental Billing Coach with Erica on her page as well in her bio. So I want you guys to bring your ugliest denials. I mean that. We're actually going to be live. We're going to be working the real ones. We're going to be bringing up real life examples. And I want you guys to know too, the reason I made that video isn't that somebody was wrong on the internet. People are wrong on the internet constantly, and I've made my peace with it and I'm okay with that. It's that this particular wrong idea, if it spreads, ends with patients not getting diagnosed. If an office hears it's not protocol anymore and quietly stops imaging or starts just writing stuff off because we don't justify anything, somebody's interproximal lesion becomes a root canal. And that root canal becomes an extraction and gingivitis becomes perio. And if we're not having the right conversations and nobody in that chain ever made a clinical decision as to why we need to take these x-rays and can prove it, then we're just gonna keep coming back to that dentist's comment. Because he was joking. He was completely serious at the time. We're in a climate where it is genuinely tempting to let clinical decisions drift toward what a payer will accept. Let's be honest, we're all in hard times. It's difficult, things are expensive. And I totally get that. But the answer isn't to get clever or creative about presentation for the insurance companies. The answer is documentation. So there's no nothing left to the imagination of the payer, and there's nothing left to argue with. So I want to leave you with five things to think over. One, radiographs were never protocol. They're standard of care. And standard of care belongs to the treating doctor in that office. Two, every practice needs that standard of care in writing, risk stratified and laid out, specific to their specialty and their patients, with what they require in order to treat them. Three, every image and honestly, every service needs an indication, a finding, a diagnosis, and a disposition or treatment plan every time. All of those parts, every single time. Those should be in the exam when we are diagnosing it, not at service time. Four, the insurance company is never the reason. The insurance company is the audience. And five, Villers, we need to stop saying you can't and start asking with what did you find? And then we do the actual skilled part of our job, which all of you are so amazing at. If you're listening to this episode, obviously you are invested in this. It's translating that into something a payer can adjudicate. I think about my toddler. I have a 14-year-old son, a 12-year-old daughter, and a four-year-old daughter. The way that I'm going to explain something to my 14-year-old son is going to be completely different than how I explain something to my four-year-old daughter. Let's think of insurance companies
Five Takeaways And Webinar Invite
SPEAKER_00as that toddler. We need to completely dumb it down for them so that they can fully understand what we are doing and why so that we can justify it. Not to get it paid necessarily, right? But to justify that's what we're doing, and we're not going to back down on that. We're going to hold to that because it was necessary. Do that, and you're not just compliant, you're defensible. And your patients are getting diagnosed and you're taking care of them the best way that you can. So thank you for listening today. Share this with your office and specifically with your doctor and your providers, because this one's just as much for them as it is for us as billers. And I'm speaking also to hygienist. Remember, our webinar is September 1st on diagnosis codes and dentistry. Link will be in the show notes. I'm Jen Lyman, co host of the Dental Billing Podcast. Thank you for listening, and I'll see you at the next episode.
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