CDBS claiming – your guide to remaining compliant with the rules

In December 2018, we advised members that the Department of Health (DoH) was investigating claims related to the Child Dental Benefits Schedule (CDBS), specifically focusing on the following item numbers:

-   88114 and 88115 (scale and clean)
-   88022 (X-rays) 
-   88161 and 88162 (fissure seals)
-   88533, 88534 and 88535 (restoration - 3 or more surfaces) 

Following a review of CDBS claims made in calendar year 2017, more than 1100 dentists, whom the DoH believed had a proportionately-higher level of claiming than average, were asked to review their records against a checklist of services they had provided and claims. Furthermore, they were asked to take action if they believed they had not been fully compliant with the administrative rules of the scheme. 

The rules around the use of these item numbers are set out in the Guide to the Child Dental Benefits Schedule. The ADA strongly recommends that if you are providing services under the scheme you take time to refresh your understanding of the rules.  (Of course, as with the provision of any treatment to patients, all procedures must be deemed clinically-relevant.)

First, you must have written consent for treatment.  If you choose to bulk bill services, you must record consent on the Bulk Billing Patient Consent form (or something similar) on the first day of service in a calendar year.  The consent form will apply for the entire calendar year however, you still have to advise the patient or parent/guardian of the treatment and the services will be bulk billed before commencing treatment on each day of service thereafter in that calendar year. 

If you are not bulk billing, you must obtain consent on the non-bulk billing consent form (or something similar) for each day and visit and ensure that there is awareness and agreement of the likely out-of-pocket costs.

Second, be aware of any annual caps, daily limitations and/or restrictions that apply on how often an item number can be claimed at any single visit/calendar year or when other item numbers are being used. 

Finally, there is a requirement for the tooth or teeth to be itemised in some situations.

The recent letters sent out by the Department relate to possible non-compliance with the last two conditions indicated above. The following information provides further clarification:

Item 88022 – Intraoral periapical or bitewing radiograph – per exposure
Taking and interpreting a radiograph made with the film inside the mouth.

There are two requirements if you are claiming this item under the scheme. First, a maximum of four radiographs can be claimed in a single day, and second, you must have documented evidence in the clinical notes that the radiograph was taken and reviewed even if no abnormality was detected. 

Item numbers 80111 –   Removal of plaque and/or stain
Removal of dental plaque and/or stain from the surfaces of all teeth and/or implants.  

There are three restrictions applied to this item number:

1. There is a limit of one claim in any five-month period.  
2. This item can only be claimed twice in any calendar year.
3. You can only claim one prophylaxis service per day so either 88111 or 88114 or 88115.

Item number 88114 – Removal of calculus – first visit
Removal of calculus from the surfaces of the teeth.

In some instances, the DoH suggests that dentists have claimed this item number without recording the presence of calculus in the clinical notes. If you wish to claim this item number you should record the presence and severity of calculus in your records to justify your actions; otherwise if you are simply removing plaque or stain, you should use 88111.

The same restrictions as item number 88111 apply.

Item number 88115 – Removal of calculus - subsequent visit
This item describes procedures in item 88114 when, because of the extent or degree of calculus, an additional visit(s), is required to remove deposits from the teeth.

A limit of two services per 12-month period applies and as per the restrictions mentioned above, cannot be claimed when 88111 or 88114 is claimed on the same day. The third issue raised in the DoH’s letters relates to fissure sealants.

Item number 88161 – Fissure and/or tooth surface sealing – per tooth (first four services on a day)
Sealing of a non-carious pits, fissures, smooth surfaces or cracks in a tooth with an adhesive material.  Any preparation prior to application of the sealant is included in this item number.

Applicable restrictions on this item number are first that there is a limit of four per day. For additional fissure sealing on the same day, there is a stepdown item number 88162.  Second, you cannot claim a benefit if you have also claimed for a restoration on the same tooth on the same day.  For this reason, you should note in your clinical records which tooth or teeth a fissure sealant has been applied.  The ADA recommends that you use the FDI Tooth Identification system you need to record the tooth or teeth. 

Approximately 200 dentists have already responded to the request to voluntarily notify the DoH of errors or simply to indicate that the claim records are correct based on their practice profile. 

Remember your clinical records support your claims so make sure your notes are extensive enough to come under scrutiny.  If you are unsure of the level of detail you should be recording refer to the Dental Board of Australia’s Dental guidelines on dental records.  It is against these guidelines that your records will be assessed if you are the subject of an audit or investigation. 

Finally, as the ADA advised in December, we recommend that if your internal review determined that you may not have met all the administrative rules of the scheme then you should contact your local ADA branch or the federal office to seek further advice.

As always, it is vital that practices are aware of their obligations under any government scheme in which they participate and that they always remain compliant. We strongly recommend that you speak with your staff involved in billing to ensure they fully understand their role in ensuring compliance.