Intra-oral Periapicals Need a Narrative

Gone are the days when frequency limitations ruled on how often intra-oral periapicals would be paid.  Often I would hear hygienists say “You are due for bitewings” and take them without determining whether the patient would really benefit from radiographs taken every year.  The dentist would not be ordering the radiographs; the hygienist and the front office were determining the need based on payment by the insurance company.

Things have changed and are changing as more insurance companies are enforcing the “evidence-based” need for dental x-rays versus the insurance company policy provision.  It may state in the policy that x-rays are a benefit every 3-5 years for FMX or every 12 months for bitewings but it also says that there needs to be a caries risk assessment and a clinical “medical necessity” to substantiate the claim.

Feedback from dental offices is showing frustration in denied periapical x-rays because the insurance company is demanding narratives and evidence that the patient needs these x-rays.  Some insurance companies are asking for an attachment of the x-ray(s) to actually see if they are of diagnostic quality before payment.  The reason for the x-ray and the diagnostic reading of the x-ray must be present in the clinical notes before including in the claim.

The clinical chart notes would look something like this:

“John W. Brown(patient) presented on (date) with a severe, constant throbbing pain in the upper right quadrant.  He pointed to the area of #2 URM.  Dr. _____evaluated the upper right quadrant and recommended a periapical x-ray taken at an angle to get the root and bone area of the tooth.  The x-ray revealed a large area of decay under an existing MODL amalgam filling and a radiolucent area at the apex of the M root.”

If you have to ask the dentist for supporting chart notes you must make sure the chart notes are amended by the clinical team before adding them to the insurance claim.  The narrative on the claim must match the clinical notes in the chart or it could be suggested that the claims filer put notes on the claim “to get it paid.”  

Success Consultants at eAssist have learned the ins and outs of filing claims for successful adjudication with the maximum reimbursement for the practice. To learn more, schedule a free consultation. 

Sandy Odle

Co-Founder and CXO, eAssist

Sandy Odle is the Co-Founder and CXO of eAssist Dental Solutions, where she has played a key role in shaping the company’s business and marketing strategies, leading to record growth and national recognition on the Inc. 500 and Utah Top 100 lists. A passionate social entrepreneur, Sandy believes that business is about building meaningful connections and creating personalized solutions that truly meet customer needs. Her relentless commitment to delivering exceptional client experiences is at the heart of eAssist’s mission. Drawing on the discipline and attention to detail honed during her early career as a ballet dancer, Sandy brings a unique blend of creativity, precision, and work ethic to everything she does.