When taking a CBCT, can you bill for other imaging instead of a CBCT to save the patient money?

You’ve purchased a Cone Beam CT (CBCT) machine. While you wait for it’s installation you and your staff have some decisions to make regarding the incorporation of this fantastic addition to your diagnostic toolbox into your imaging protocol. You also have correctly identified that while patients love their dentists to have the latest technologies, no one likes feeling that they are the ones footing the bill for this impressive three-dimensional tool. You’ve no doubt invested a significant amount of money for this purchase, and as such these are legitimate questions you need to consider.

Since the early 2000s Cone Beam CT has been available in the United States, becoming increasingly more affordable and therefore more widespread in the practice of dentistry. From implant treatment planning, visualization of pathology in three-dimensions, to getting an image of that unknown entity in a panoramic, Cone Beam CT is a fantastic addition to the dentist’s diagnostic quiver. We’ve already discussed the importance of considering how much of the patient we want or need to capture when acquiring a volume in our last blog post. As part of that we touched briefly on the radiation costs to the patient, and we will touch on that again here shortly. What will be the primary focus of our discussion this time is the appropriateness of taking a CBCT as a screening tool and if one should try to save the patient money by billing the patient’s insurance company for a different, less expensive, imaging series. Let’s start by addressing the pesky question of radiation dose.

Radiation Dose – Know your CBCT

Evaluation of radiation dose to the patient is a non-controversial issue with recommendations and guidelines we are familiar with – from ALARA (As Low As Reasonably Achievable) to Image Gently, there is no shortage of reminders of our duty to our patient’s regarding radiation dose. Where it gets more complicated, however, is when we start comparing different Cone Beam CT units, panoramic units, and intraoral units.

While it’s easy to make broad generalizations in regards to dose from any of the radiology modalities utilized in dentistry, in reality there is quite a wide range. This range is dependent on the age of the unit, digital vs. film, and if the equipment is utilizing other inherent factors to reduce dose to the patient (e.g. long tube vs. short tube, rectangular vs. round). All of this is to say that you need to be familiar with your equipment and the actual dose you’re working with that is particular to your office.

This dose comparison is unique to your practice. As we discuss whether we should be taking a CBCT in place of panoramic, four bitewings and individual periapicals we must account for the differences in the equipment your office is using. Outside of standard doses for a particular type of unit, other factors should be considered as well, such as resolution of these modalities. While CBCT is a useful tool for many things, the preferred image to detect interproximal caries is the intraoral bitewing radiograph.¹

The selection of the appropriate field of view also has an impact on radiation exposure. As mentioned previously in our blog post on Field of View, reduction of the field of view can result in “patient dose reductions ranging from 25% to 66% depending on the machine, type of collimation (vertical or horizontal), amount of mechanical collimation, and location (maxilla vs. mandible; anterior vs. posterior).”² And this makes sense as the larger the volume that is acquired, the more dose is imparted to the patient. This is particularly important when we are talking about pediatric patients and taking larger volumes.

While many are happy to invest in new equipment that wows our patients and helps sell their treatment plans more effectively, we should also consider the beneficial impact to our patients by updating our current intraoral equipment to help reduce radiation dose on what is often routine radiographic procedures in our office. In short, the devil is in the details.

What Does the ADA / FDA / AAOMR Have to Say About It?

Just as there is not a one size fits all for what radiographs should be taken on a patient due to caries risk, etc., the FDA and ADA “Guidelines for the Selection of Patients for Dental Radiographic Examinations-2004” provides useful information for justifying the tailoring of the radiographic examination to the patient. The FDA “recommends imaging professionals follow the principles of justification and optimization in the protection of patients undergoing radiological examinations.”³ More specifically the FDA recommends the following:

1. “Discuss the rationale for the examination with the patient and/or parent to ensure a clear understanding of benefits and risks.
2. Reduce the number of inappropriate referrals (i.e., justify X-ray imaging exams) by: determining if the examination is needed to answer a clinical question, considering alternate exams that use less or no radiation exposure, and reviewing the patient’s medical imaging history to avoid duplicate exams.
3. Use exposure settings for dental CBCT exams that are optimized to provide the lowest radiation dose that yields an image quality adequate for diagnosis (i.e., radiation doses should be “As Low as Reasonably Achievable”). The technique factors used should be chosen based on the clinical indication, patient size, and anatomical area scanned, and the equipment should be properly maintained and tested.”³

The American Academy of Oral and Maxillofacial Radiology (AAOMR) Executive Committee in its Executive Opinion Statement on Performing and Interpreting Diagnostic Cone Beam Computed Tomography states that it “believes that the practitioner should apply imaging procedures based on considerations of patient radiograph selection criteria, dose optimization, technical proficiency, and assessed diagnostic or treatment needs”² and, “CBCT examinations should be performed only for valid diagnostic or treatment reasons and with the minimum exposure necessary for adequate image quality.”²

All this to say, don’t apply a one size fits all radiographic treatment plan to the patient before evaluating them clinically. It is second nature for us to customize our dental treatment plans based on our clinical knowledge for restorative, endodontics, periodontics, oral surgery, etc. – our radiographic treatment plan should be no different and should be customized based on what we see clinically and what is known of the patient’s medical and dental history.

Liability

No discussion of practicing dentistry in an area that encompasses a dental specialty is complete without a discussion on liability. Evaluating radiographs is often a daily task for most dentists and dental specialists, so it should come as no surprise that when we are discussing being knowledgeable to comfortably and reliably interpret intraoral (periapicals, bitewings, etc.) and panoramic radiographs, there is no conversation needed regarding the capabilities of the dentist as we received formal education encompassing these radiographic modalities. CBCT, however, is still in its infancy at many institutions and therefore many dentists have not received formal training while in dental school. This is not to say that one cannot become competent in this particular area of dentistry. The AAOMR in it’s own executive opinion has stated as such: “It is desirable for practitioners to undergo specific training to perform CBCT examinations successfully.”²

Similar to seeking out additional training to perform bony impacted third molars, the standards of care are elevated to the specialty you are now encompassing, “Dentists using CBCT should be held to the same standards as board certified oral and maxillofacial radiologists (OMFRs), just as dentists excising oral and maxillofacial lesions are held to the same standards as OMF surgeons.”² As is the case with any other radiograph acquired in dentistry it is ”the responsibility of the practitioner obtaining the CBCT images to interpret the findings of the examination. Just as a pathology report accompanies a biopsy, an imaging report must accompany a CBCT scan.”² This really should not be surprising to anyone as we all have the ability to elevate a patient’s care to a higher level and part of our training involves knowing when to do so.

Back to the discussion of taking a CBCT in place of other radiographs: a consideration outside of radiation exposure to the patient will be your comfort level in interpreting regions outside of the jaws and teeth. As is true with any radiographic image acquired in dentistry, we are responsible for reviewing the entirety of it. A systematic approach should be taken with careful observation to identify abnormalities. In a CBCT acquired to create a reconstructed panoramic image, this will involve capturing the base of the skull, paranasal sinuses, cervical spine, and the airway spaces. If this is outside your comfort level, it is imperative to the overall health of the patient this evaluation be elevated to an an Oral and Maxillofacial Radiology (OMFR)  specialist: “Qualified specialist OMFRs may be able to assist diagnostically when practitioners are unwilling to accept the responsibility to review the whole exposed tissue volume.”²

As Oral & Maxillofacial Radiologists, we are here to assist when regions are captured outside your comfort and ability. This is especially true when a dentist purchases a CBCT for the first time and is learning where that line is.

Billing Appropriately

You’ve selected the appropriate radiographic examination for your patient, and it involves 4 intraoral bitewings and a CBCT. The question often arises: can you bill for a full mouth series and save your patient some money? The short answer is simply no.

The American Dental Association has a wealth of information when it comes to proper billing procedures, specifically radiographic procedures. It acknowledges that decisions concerning CDT Code selection are up to the individual dentist and may be influenced by factors that are not always easily discussed in broad generalizations. It is important to remember that the purpose of the CDT Code is to document what took place in the office and does not always translate into complete reimbursement for the procedure. Dentists should always select the CDT Code that, in their clinical opinion, accurately describes the procedure delivered to the patient. Throughout the ADA’s provided videos and documentation, one key phrase is repeated time and time again: code for what you do, and do what you coded for.⁵

The next question that is often asked is what about new images created from a radiograph acquired – creating a bitewing from a panoramic radiograph for example? Can I bill for the bitewing? The appropriate code is for the initial image captured, not what can be created from it. This also applies to creating a panoramic radiograph (a reconstructed panoramic as it is more appropriately called) and billing for a panoramic radiograph. Again, you should code for what you captured. You do not want to be held accountable for billing the incorrect code and now being liable for the totality of reimbursable claims for the radiographs. As a common procedure in the office you could be facing a very large bill from the insurance company.⁵

If you’re overarching concern is to save the patient money, the safest way to charge the patient less is to set your billing fee for a procedure – such as a CBCT – to a lower amount that the patient can afford. Most importantly this retains the legal record of what dental procedure was completed for the patient.

Cone Beam CT is a fantastic addition to the dentist’s diagnostic toolbox when considering the radiographic treatment plan of each patient. The cost of radiation for each individual modality is inherently unique to each practice and should be considered in a case by case scenario with the guidelines provided by the ADA and FDA. Referral to a higher level of care (i.e. Oral & Maxillofacial Radiologist) should be considered if the totality of the image you require is outside your comfort level of interpretation. Finally, consider billing less for your CBCT CDT codes if you want to save them money as the CDT codes are an important part of the patient’s record of treatment rendered.

Ryan Holmes, DDS

Oral & Maxillofacial Radiologist / Co-Founder

True View Dental Radiology

References

1. Mallya SM, Lam E. White and Pharaoh’s Oral Radiology: Principles and Interpretation

8th ed., St. Louis: Elsevier Mosby; 2018: 304.

2. Carter L, Farman AG, Geist J, Scarfe WC, Angelopoulos C, Nair MK, Hildebolt CF, Tyndall D, Shrout M; American Academy of Oral and Maxillofacial Radiology. American Academy of Oral and Maxillofacial Radiology executive opinion statement on performing and interpreting diagnostic cone beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008 Oct;106(4):561-2. doi: 10.1016/j.tripleo.2008.07.007. PMID: 18928899.
3. “Dental Cone-beam Computed Tomography.” U.S. Food and Drug Administration, https://www.fda.gov/radiation-emitting-products/medical-x-ray-imaging/dental-cone-beam-computed-tomography
4. “Coding Education.” American Dental Association, https://www.ada.org/en/publications/cdt/coding-education