Use of item numbers - The Australian Schedule of Dental Services

When managing complaints, the Council and/or the Health Care Complaints Commission provide practitioners with the opportunity to respond to the complaint. When the complaint is one that relates to conduct and/or performance, clinical records are almost always expected as one component of that response.  Once again, we should stress that seeking advice from your indemnifier or professional association is a critical first step before submitting your written response.

Item numbers are an integral part of the clinical record. For those new to practising in New South Wales, or colleagues who need a gentle reminder, the Australian Schedule of Dental Servicesopen_in_new (commonly known as the “ADA Schedule”) provides all registered practitioners with clearly described codes to use for the care that you provide. 

First developed in 1986, the ADA Schedule is currently under review and until the 2025 version is released, item numbers used in the 13th Edition (2022) should be used to standardise service descriptions and facilitate insurance claims.

Misuse of item numbers can have legal consequences and may raise serious ethical concerns about clinical care provided. Over recent times, the Council has noted some inconsistencies around the use of item numbers. Some common examples include:

• providers using a ‘cut and paste’ list of item numbers at an initial examination
• comprehensive examination claims for examinations that are limited in nature
• the addition of item numbers where there is no clinical record to support the claim made
• providers using item numbers that attract a higher insurance rebate to ‘support’ their patients.

Unlike the Medicare Benefits Schedule that has legal requirements for use, usage of the ADA item numbers relies heavily on clinical judgement and ethical conduct. Inflating or fabricating item numbers can mislead both patients and insurers, thus undermining trust in oral health care and professional integrity. Correct use of item numbers is an integral component of informed consent, quoting and invoicing.

Misuse of item numbers can constitute insurance fraud which may in turn lead to audits, investigations, fines, loss of provider status, and even criminal charges.

Inaccurate billing could also be considered deceptive conduct under consumer protection laws, and this may make your practice liable to legal action from patients or regulators.

To minimise your risk, we suggest that you ensure that all members of your team have access to the ADA Schedule and that you update this document when version 14 is available. If you have concerns about one of your colleagues using inappropriate item numbers, a random and periodic audit within your practice may help as an educative tool. It is important to make sure that your clinical records and patient communications support the item numbers that you use and if in doubt, access the guidance and information in the ADA Schedule or reach out to the ADA Schedule Committee.

Misuse of dental item numbers may be unintentional, but we stress that their appropriate use is critical for public trust and safety.