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MyView: Medical necessity: friend or foe?

May 18, 2015

By Allen Finkelstein, D.D.S.

Allen Finkelstein, D.D.S.
Last year, hundreds of Nebraska dentists were sent letters from the state's Medicaid recovery audit contractor asking for charts containing adult and pediatric codes for prophylaxis. The auditor demanded documentation of dental/medical necessity for every prophylaxis.

We know similar situations are happening across the country. How do we as practitioners deal with this? To quote Albert Einstein: "We don't need to think more, we need to think differently."  Here are some basic suggestions to help make the Medicaid experience work for both the patient and the dentist.

First, some background: Section 6411 of the federal Patient Protection and Affordable Care Act directs states to establish programs in which they will contract with one or more recovery audit contractors to reduce improper payments to providers of Medicaid services. The RAC program allows private contractors to demand patient records and conduct audits on providers verifying medical necessity and payment while retaining a percentage of any refunds collected.  

"Medical necessity" is accepted health care services and supplies provided by health care entities appropriate to the evaluation and treatment of a disease condition, illness or injury and consistent with applicable standard of care. Furthermore, dental care is medically necessary to prevent and eliminate orofacial disease, infection and pain; to restore form and function to the dentition; and to correct facial disfiguration or dysfunction. Medical necessity should be documented to establish the rationale for the procedure and support the selected Current Dental Terminology Code.

Questions that should be addressed in the documentation include:

  • Is the procedure necessary for the patient's condition?
  • Does the record contain all supporting documentation for diagnosis and treatment?
  • When multiple treatments are provided, are all the treatments/procedures documented individually?
  • Are the records signed by the individual provider?
  • Are there contraindications concerning the care or procedures performed within the documentation and are they adequately justified?

For a service to be considered medically necessary, that service must be reasonable and necessary to diagnose or treat a patient's dental/medical condition. Documentation of dental care should accurately reflect the need and outcome of the treatment. Documenting medical necessity is an important aspect in substantiating the rationale of treatment and therefore an important element for a successful provider audit.

Because the dental profession does not as yet utilize accepted diagnostic codes, as is the case for the medical profession, the provider must document the diagnosis for all procedures performed that confirm the use of the submitted procedure code.

The lack of accepted diagnostic codes is not an insurmountable challenge.

For example, when performing prophylaxis, simply document that the procedure is being performed to control local irritating factors that are present on the patient's tooth surface(s). The patient risk assessment can be used to support this documentation.

Dentists should accept the fact that as a patient/member advocate, they should submit a prior approval for treatment they deem medically necessary, even if the treatment plan extends beyond the state's Medicaid program's benefits. If increased prophylaxis frequency based on the patient's risk assessment is needed, a prior authorization request should be submitted to the insurer.

Risk assessment strategies are used to gauge potential difficulties in treatment execution in order to understand the potential of success in treatment outcomes. Treatment plans should be developed by identifying achievable clinical goals determined by medical necessity.

Auditors are also questioning the number and type of radiographs that providers submit for reimbursement. Medical necessity based on established patient risk assessment outcomes should determine the number and frequency of radiographs. Age of the patient, although important for growth and development, should not be the only determinant for radiographic utilization.

A thorough clinical examination, consideration of the patient history, review of any prior radiographs, caries risk assessment and consideration of both the dental and the general health needs of the patient should precede radiographic examination. American Dental Association guidelines support that radiographic screening for the purpose of detecting disease before clinical examination should not be performed.

Providers should be aware that when submitting a claim for payment, the treatment codes reported should be supported by corresponding documented medical necessity, including prophylaxis and radiographs. By following this methodology, the provider has established "why" a service has been performed, thus making a challenge from an audit agency extremely difficult.

Consistent use of correct, appropriate and corresponding procedure codes is critical in establishing medical necessity and by doing so, health care providers are afforded the opportunity to tell their stories. Each story should be unique to the care each provider has determined as appropriate and should be told accurately by properly documenting the treatment to support why the treatment has been rendered.

Used properly, medical necessity can be your friend and diminish the opportunities of your perceived foes, especially when RAC auditors and other oversight agencies will be conducting legislative-directed audits. These audits being conducted for what would seem to be reasonable and proper rationale have the potential to drive good providers out of the Medicaid program. The key is to learn from the audit practices and embrace medical necessity as an integral part of risk assessment based treatment. CMS has offered technical assistance in this area, which can be found at by searching "dental care."

Dr. Finkelstein is a member of the ADA Council on  Access, Prevention and Interprofessional Relations' Medicaid Provider Advisory Committee.  He is also the CEO of Bedford Healthcare Solutions and the former chief dental officer of AmeriChoice/United Health Group.