Chapter 4:
Dental Services Provided to Title XIX Recipients and An Evaluation of Title XIX Reimbursement LevelsThe allowed charges for all dental services during FY 1994 was $20,251,528. The total allowed charges for many of the most common dental procedures for all recipients during FY 1994, (the most current year for which data was available by procedure), are shown in Table 4-1. Allowed charges are the amount Title XIX would pay for a procedure (without consideration of copayments, third party coverage, or patient costs prior to eligibility for the medically needy program).
Table 4-1. Number of procedures and Title XIX total
allowed charges for selected dental procedures (FY 1994)
Procedure Procedure code Title XIX allowed charge Number provided Total allowed charges Comprehensive oral examination 00110 $12.25 43872 $532,285 Periodic oral evaluation 00120 $9.80 81527 $791,913 Limited oral evaluation (emergency with Tx) 00130 $14.71 8356 $120,875 2 bitewing x-rays 00272 $10.43 41503 $427,674 4 bitewing x-rays 00274 $12.25 9243 $112,562 Adult cleaning 01110 $25.70 9132 $730,822 Child cleaning 01120 $14.61 7581 $109,052 Fluoride--child 01201 $25.04 38017 $942,263 Fluoride--adult 01205 $36.14 27824 $987,654 Sealants (per tooth) 01351 $7.82 15217 $118,938 Silver filling--1 surface, primary 02110 $19.60 7988 $156,137 Silver filling--2 surface, primary 02120 $26.97 10337 $277,867 Silver filling--1 surface, permanent 02140 $22.07 32728 $721,065 Silver filling--2 surface, permanent 02150 $31.29 24354 $761,141 Silver filling--3 surface, permanent 02160 $41.72 10562 $439,365 Silver filling--4 surface, permanent 02161 $50.06 3898 $194,733 White filling--1 surface, anterior 02330 $24.52 12709 $310,752 White filling--two surfaces anterior 02331 $34.32 6950 $237,863 White filling--three surfaces anterior 02332 $45.36 4217 $190,327 White filling--4 surf, anterior/incisal angle 02335 $47.81 5029 $239,246 White filling--1 surface, posterior 02385 $24.57 6745 $165,266 Crown--porcelain fused to base metal 02751 $57.47 5167 $1,328,670 Crown--full cast base metal 02791 $203.52 4324 $879,910 Crown--stainless steel (primary) 02930 $49.04 6125 $298,557 Vital pulpotomy (remove part of nerve) 03220 $30.65 3523 $105,778 Root canal--anterior 03310 $134.86 2288 $302,704 Root canal--bicuspid 03320 $165.52 1379 $226,406 Root canal--molar 03330 $232.96 2546 $586,228 Root planning--gums (per quadrant) 04341 $68.66 4901 $331,307 Periodontal scaling--gum inflammation 04345 $34.32 5386 $180,396 Complete upper denture 05110 $367.83 2446 $886,902 Complete denture--mandibular 05120 $367.83 1925 $696,144 Posterior upper partial denture, cast base 05213 #380.08 931 $353,200 Posterior lower partial denture, case base 05214 $373,95 867 $323,404 Extraction--single tooth 07110 $23.29 17443 $402,462 Extraction--additional tooth 07120 $22.07 23881 $524,458 Extraction--ruptured tooth 07210 $30.65 5813 $177,970 Construct and place maxillary appliance 08550 $220.69 975 $192,935 Construct and place mandibular appliance 08551 $220.69 878 $192,935 Orthodontic treatment maxillary arch--braces (cost per 3 months treatment) 08552 $73.56 5376 $388,494 Orthodontic treatment mandibular arch--braces (cost per 3 months treatment) 08553 $73.56 5036 $364,043 Iowa dentists ranked low fees as the most important problem with the Title XIX program. The last increase in fees reimbursed by Title XIX was a four percent across the board increase in 1991. This study was conducted to evaluate how current Title XIX fees compare with the fees charged by dentists in private practice. The private practice fees used in this comparison were collected by Professional Economics Bureau of America, a Minneapolis-based consulting firm. This company conducts a yearly survey of private practitioners' dental fees in Iowa. Fees for 1995 were received from 257 Iowa dentists, a relatively large number of fee schedules. This, however, represents fee schedules from only about 20 percent of all Iowa dentists so there is a chance that these fees are biased either high or low.
Comparisons of Iowa Title XIX allowable charges and the average private practice fees are shown by procedure for the state in Table 4-2. On average, across all procedures, Title XIX allowable charges were about 62 percent of the private practice fees. This percentage varied significantly by procedure. The lowest percent reimbursement (about 50 percent) was for procedures such as one surface fillings (composite resin and amalgam restorations), comprehensive examinations, single tooth extractions, and sealants. The highest relative reimbursed amounts (about 75 percent) were for a large white filling on a front tooth (4 surface composite resin restoration), X-rays taken of the entire mouth or all of the teeth (full mouth series or panorex) and for intensive gum therapy (root planing and periodontal maintenance). Emergency exams appear to have a high relative fee, however, Title XIX fees include necessary treatment where the private fees typically only include the emergency examination.
Table 4-2. Comparison of average private practice fees with Title XIX reimbursement
rates for the most common dental procedures
Dental procedure Procedure code Title XIX allowable charges Iowa private dentists mean charge Title XIX allowed charge as a percent of Iowa dentist fees Comprehensive oral examination 00110 $12.25 $23.44 52.3% Periodic oral evaluation 00120 $9.80 $15.84 61.9% Limited oral evaluation (emergency with Tx) 00130 $14.71 $18.04 81.5% 2 bitewing x-rays 00272 $10.43 $15.22 68.5% 4 bitewing x-rays 00274 $12.25 $23.21 52.8% Full mouth x-rays 00210 $36.51 $49.11 74.3% Panoramic x-ray film 00330 $35.40 $44.30 79.9% Adult cleaning 01110 $25.70 $33.63 76.4% Child cleaning 01120 $14.61 $22.50 64.9% Sealants (per tooth) 01351 $7.82 $17.73 44.1% Silver filling--1 surface, permanent 02140 $22.07 $40.42 54.6% Silver filling--2 surface, permanent 02150 $31.29 $51.88 60.3% Silver filling--3 surface, permanent 02160 $41.72 $63.07 66.1% Silver filling--4 surface, permanent 02161 $50.06 $75.23 66.5% White filling--1 surface, anterior 02330 $24.52 $48.28 50.8% White filling--4 surf, anterior/incisal angle 02335 $47.81 $58.85 81.2% White filling--1 surface, posterior 02385 $24.57 $52.41 46.9% Crown--porcelain/base metal 02751 $251.34 $392.75 64.0% Crown--full cast base metal 02791 $208.52 $416.58 50.0% Crown--stainless steel 02931 $49.04 $101.56 48.3% Root canal--anterior 03310 $134.86 $226.13 59.6% Root canal--bicuspid 03320 $165.52 $279.13 59.3% Root canal--molar 03330 $232.96 $357.21 65.2% Root Planning-gum (per quadrant) 04341 $68.66 $91.33 75.2% Gum maintenance 04910 $43.16 $51.95 83.1% Complete denture--mandibular 05120 $367.83 $585.73 62.8% Partial denture--maxillary 05213 $380.08 $626.56 60.7% Extraction--single tooth 07110 $23.29 $47.76 48.8% Summary
Title XIX fees averaged 62 percent of the average private practice dental fees in Iowa. With dental office overhead expenses generally running 65 percent of total costs, dentists tend to perceive that Title XIX reimbursement is below the cost of providing services. The percent reimbursement, however, varies significantly by procedure. In addition, it is important to consider the cost of seeing one additional patient (the marginal cost) instead of the total overhead when determining whether a dentist is able to provide care to Title XIX patients at a profit. For example, the overhead costs associated with seeing one additional Title XIX patient if there is an open appointment time is significantly less than if a Title XIX patient replaces a private patient in the schedule. Fees are relatively low for many of the most common routine procedures.
