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2012
Proper Implementation of the Electronic Health Record (EHR)
Coding Correctly
With CEREC
all cerec doctors understand how
technology is impacting dentistry. Now,
these same changes that have affected our
clinical lives are also becoming a larger
portion of our non-clinical activities —
including the electronic health record
(
EHR). Many of us have already heard of
this and are making it a portion of daily
practice. For those using this system, this
article will help explain the importance of
its proper use, particularly codes.
Miscoding is analogous to writing
the wrong progress note on the patient.
Worse yet, these errors can lead to claims
of fraud that could potentially jeopardize
one’s license. Therefore, it is becoming
increasingly important for dentists to stop
delegating coding to non-clinical staff who
are not present when treatment is being
rendered. (One can certainly delegate
this to the assistant or hygienist who was
present, since he or she should be well
aware of what treatment just occurred.)
Think of mis-coding this way: You go
to a restaurant and order the prime-cut
steak; the waiter brings chicken. This is
exactly what occurs in instances when
the doctor calls a restoration an onlay or
crown when, in fact, it may be an inlay.
While it may seem that one may be doing
the patient a service by getting better
benefit coverage from their insurance, it is
much more of a
dis
service — to everyone.
We have all experienced the frustration
of benefit companies denying submis-
sions from our CEREC-produced resto-
rations. Numerous conversations I’ve
had with people involved in
making these benefit deter-
minations clearly indicate
that we, as dentists, have
P R A C T I C E M A N A G E M E N T
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b y S t e p h e n C . U r a , D . D . S . , M . A . G . D .
brought a good portion of these denials
on ourselves. However, that also means
we, as dentists, can change this with more
careful coding and a better understanding
of when a crown is a crown and when an
onlay is an onlay.
Most of the coding issues that CEREC
doctors experience do seem to revolve
around onlays. This can be resolved by
simply having a better understanding of
what constitutes an onlay. It is even more
important to know what distinguishes
the onlay from the inlay. Quoting from the
ADA Glossary:
onlay:
A dental restoration made outside
the oral cavity that covers one or
more cusp tips and adjoining occlusal
surfaces, but not the entire external
surface. It is retained by luting cement.
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inlay:
An intracoronal dental restoration,
made outside the oral cavity to conform
to the prepared cavity, which restores
some of the occlusal surface of a tooth,
but does not restore any cusp tips. It is
retained by luting cement.
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Another way to look at this is that when
the restoration
crosses the cusp tip
,
you
have moved from inlay to onlay. Contrary
to what some have preached,
it is not
when you go up a significant portion of
the cuspal incline. Therefore, if you keep
the threshold that you have crossed the
cusp tip (needed to remove the 2 mm for
ceramic clearance), you have “covered
the cusp” which defines the onlay. From
there, you need to indicate the surfaces
to determine whether you are two, three
or four surfaces. Personally, I find it very
difficult to have a two-surface onlay.
What about the onlay versus crown?
Let us again look at the definition from
the ADA Glossary:
crown:
An artificial replacement that
restores missing tooth structure by
surrounding the remaining coronal
tooth structure, or is placed on a dental
implant. It is made of metal, ceramic or
polymer materials or a combination of
such materials. It is retained by luting
cement or mechanical means.
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In short, you can consider it an onlay
when you need to primarily replace the
coronal portion of a tooth, while a crown
occurs when replacing the majority of
the clinical crown. Generally, when you
are replacing one to three cusps, you
are in onlay territory; but when you are
moving on to the fourth cusp, you poten-
tially may be moving into the crown. Take
a look at your cervical margin. When it
is approaching the gingival level, start
looking at the circumference. Once
you cross the 180-degree level and are
through the mesial, distal and either the
lingual or buccal surface, you are in crown
range. At that point, the question is, is it a
three-quarter crown or full crown?
So, what happenswhen you’ve coded for
exactly what you’ve done, and it still gets
denied? Many of these denials happen
due to a process called “auto-adjudica-
tion,” which means an actual person has
not seen the claim. Every time a person
interacts with a claim, it costs the insur-
ance companies money. Therefore, many
of these claims “auto-adjudicate,” meaning
the benefit is determined by a computer
algorithm. Given some of the history of
ceramic onlays, some companies have
resorted to automatic rejection of ceramic
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