Montana Dental Association

Montana Dental Association
May 2, 2013

Optimize your Practice:
Understanding the CDT Code v.2013 (and More) Seminar is offered as information only Not as professional advice (e.g., financial, accounting, legal) Consult with your own professional advisors for such advice Presentation material is copyrighted No reproduction of any content without express written ADA consent This workshop is intended to: Explain major changes found in the current Code, effective January 1, 2013 Describe how new codes integrate with continuing codes used in your practice Help you be more efficient by developing and refining your Code knowledge Provide guidance on Code use based on CDBP perspective Highlight features of dental and medical claim form completion Your are in the best position to make clinical decisions Your questions about situations you’ve encountered will make this session a richer, relevant learning experience Prepared for you by the Council on Dental Benefit Programs

Brought to you by… ADA’s Council on Dental Benefit Programs CDBP has responsibility for > Maintaining and promoting use of dental coding taxonomies > Addressing third-party payer actions that intrude on the dentist-patient relationship >Providing dentists with educational and reference material that supports day to day practice administation

Learning Objectives- to understand…
The Code’s structure and recent changes Ways the Code supports documenting procedures of varied complexity and one or more dates of service Basic dental and medical claim submission How to identify and address problems with payer claims adjudication Payer cost containment and risk management

Disclaimer Not b…. session
Not a course on how play the insurance game or bend the code Not particularly about “why 3rd party payers won’t pay for this or that” It is about how to code for what you do ..and Better prepare your office for the transition to electronic records

What is the CDT Code Shorthand for the ADA’s Code on Dental Procedures and Nomenclature

The Code and “ CDT” are not the same thing
Code = Code on Dental Procedures and Nomenclature CDT = Current Dental Terminology > The ADA publication containing the Code > And more

Why a CDT Code? Purpose – Use –
Provide uniformity, consistency and specificity in accurately reporting (i.e., documenting) dental treatment Use – Populate patient health record – electronic and paper Provide for the efficient processing of dental claims Code first published in the Journal of the American Dental Association (JADA) Consisted of numbers and a brief name, or nomenclature 1972 “Uniform” dropped from name Published in separate manuals since 1990, titled “Current Dental Terminology” or CDT CDT-1 marked the addition of Descriptors (definitions) for most of the procedure codes Code is the HIPAA standard code set for reporting dental procedures, and requires the ADA, as the Code’s owner, to Review it yearly Set the effective and expiration dates for each version Code supports two broad categories of activities: Treatment planning and clinical record keeping Claim submission and encounter reporting Code provides uniformity, consistency and specificity in reporting dental treatment Treatment plans must be developed According to professional standards NOT according to the provisions of the dental benefit contract Always keep in mind: Existence of a procedure code does not guarantee there is a covered benefit Remember: Code for what you do, not to fit an dental benefit plan

CDT Manual Preface “…the following points should prove helpful when recording services on the patient record, and when reporting procedures on a paper or electronic claim submission. 1. The existence of a dental procedure code does not mean that the procedure is a covered or reimbursed benefit in a dental benefit plan.”

Categories of Service I. Diagnostic D0100- D0999 VII.
Maxillofacial Prosthetics D5900- D5999 II. Preventive D1000- D1999 VIII. Implant Services D6000- D6199 III. Restorative D2000- D2999 IX. Prosthodontics - fixed D6200- D6999 IV. Endodontics D3000- D3999 X. Oral and Maxillofacial Surgery D7000- D7999 V. Periodontics D4000- D4999 XI. Orthodontics D8000- D8999 VI. Prosthodontics – removable D5000- D5899 XII. Adjunctive General Services D9000- D9999 first version of the Code had 10 categories of service 1982 – category for Maxillofacial Prosthetics added 1990 – 12th category added for Implant Services 11 of the 12 categories of service have subcategories Maxillofacial Prosthetics is the exception because no call from the profession to have subcategories One example of subcategories – Diagnostics D0100 – D0999 Clinical Oral Evaluations D0120 – D0180 Radiographs/Diagnostic Imaging D0210 – D0363 Tests and Examinations D0415 – D0470 Oral Pathology Laboratory D0472 – D0502 Other examples of subcategories: In Endodontics - Pulp capping, pulpotomy, endodontic therapy on primary teeth, etc. In Periodontics - Surgical services, non-surgical periodontal services, etc. In Prosthodontic (Removable) - Complete dentures, partial dentures, adjustments to dentures, etc.

Components of a CDT Code entry
Procedure Code Five character alphanumeric beginning with “D” Nomenclature (name) Written title of the procedure D0210 intraoral - complete series of radiographic images A radiographic survey of the whole mouth, usually consisting of periapical and posterior bitewing images… “Enter” key or one “left-click” on the mouse will initiate automatic display of red borders, arrows and text – starting with procedure code and ending with descriptor This slide illustrates how an individual Code entry is structured Procedure Code (Letter and Number) Each Procedure Code is printed in boldface type in the CDT manual Letter “D” is an integral part of a procedure code, it is required “D” differentiates dental procedure codes from codes in other medical code sets Nomenclature (Name) Each procedure code must have a nomenclature that is also printed in boldface type Descriptor (Description) Most, not all, procedure codes have their own descriptor Follows the applicable dental procedure code and its nomenclature A descriptor that applies to a series of codes precede the series When present, descriptors are printed in regular typeface Descriptor (description) Narrative providing further definition and intended use of the procedure; most but not all codes have a descriptor

Changes effective – 01/01/2013 35 additions across eight categories
Diagnostic / Preventive / Restorative / Periodontics / Implant Services / Prosthodontics, fixed / OMS / Adjunctive 37 revisions across nine categories Diagnostic / Preventive / Restorative / Endodontics / Periodontics / Implant Services / Prosthodontics, fixed / OMS / Adjunctive 12 deletions across four categories Diagnostic / Preventive / Periodontics / Prosthondontics, fixed

Classification of Materials
Relocated to precede all categories of service Porcelain/Ceramic revised Refers to those non-metal, non resin inorganic refractory compounds processed at high temperatures (600C/1112F and above) and pressed, polished or milled – including porcelains, glasses, and glass-ceramics Refers to pressed, fired, polished or milled materials containing predominantly inorganic refractory compounds – including porcelains, glasses, ceramics and glass-ceramics This classification of materials change is ONLY for the purposes of coding. It does not change the definition of dental materials from a scientific standpoint.

Diagnostics – Major Actions
Revision and expansion of Diagnostic Imaging subcategory Evolutionary changes to imaging modalities New Subcategory for “Pre-diagnostic Services Regulatory changes for increased patient access to care

Diagnostic Imaging – 3 Sub-subcategories
Image capture with interpretation Continuing image capture and interpretation (e.g., FMX; BW) within the dentist’s office Image capture only Separate facilities for MRI, Ultrasound and other special imaging Interpretation and report only Practitioners who specialize in analyzing diagnostic images

Change “film” to “radiographic image”
“Film” is out-of-date term All nomenclatures with “film” revised Example – Before change: D0270 bitewing – single film As revised: D0270 bitewing – single radiographic image

Pre-diagnostic Services
D0190 screening of a patient A screening, including state or federally mandated screenings, to determine an individual’s need to be seen by a dentist for diagnosis. D0191 assessment of a patient A limited clinical inspection that is performed to identify possible signs of oral or systemic disease, malformation, or injury, and the potential need for referral for diagnosis and treatment.

Preventive – One for two
One addition as replacement for two deletions – D1208 topical application of fluoride D1203 topical application of fluoride – child D1204 topical application of fluoride – adult Why the replacement? NOTE: D1208 is not used when the material is fluoride varnish Topical fluoride (e.g., gel; foam) is applied in the same manner no matter what type of dentition is present

Preventive – One revision
Before change – D1206 topical fluoride varnish; therapeutic application for moderate to high caries risk patients Application of topical fluoride varnish, delivered in a single visit and involving the entire oral cavity. Not to be used for desensitization. As revised – D1206 topical application of fluoride varnish No reason varnish application should be constrained by level of caries risk NOTE: D1206 is used only when the material is fluoride varnish

Restorative – Highlighting 2 additions
D2990 resin infiltration of incipient smooth surface lesions Placement of an infiltrating resin restoration for strengthening, stabilizing and/or limiting the progression of the lesion. D2929 prefabricated porcelain/ceramic crown – primary tooth No notes

Restorative – Highlighting 2 revisions
No more arbitrary time criteria! D2799 provisional crown Crown utilized as an interim restoration of at least six months duration during restorative treatment to allow adequate time for healing or completion of other procedures. This includes, but is not limited to changing vertical dimension, completing periodontal therapy or cracked-tooth syndrome. This is not to be used as a temporary crown for a routine prosthetic restoration. D2799 provisional crown – further treatment or completion of diagnosis necessary prior to final impression Not to be used as a temporary crown for a routine prosthetic restoration. No Notes

Restorative – Highlighting 2 revisions
D2955 post removal (not in conjunction with endodontic therapy) For removal of posts (e.g., fractured posts); not to be used in conjunction with endodontic retreatment (D3346, D3347. D3348) D2955 post removal Post removal is a discrete procedure – delivered in the same manner without regard to any subsequent discrete procedure

From Last Year D2940 Protective restoration Direct placement of a restorative material to protect tooth and/or tissue form. This procedure may be used to relieve pain, promote healing, or to prevent further deterioration.

Endodontics – Revise Subcategory
Endodontic Retreatment This procedure may include the removal of a post, pin(s), old root canal filling material, and the procedures necessary to prepare the canals and place the canal filling. This includes complete root canal therapy. Procedure codes document discrete services Vague (e.g., “…may include…) text diminishes clarity and accurate documentation of services provided No notes

Periodontics – Addition (& revisions)
D4212 gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth New code applicable whether or not suprabony pockets exist D4210 and D4211 descriptors revised References to procedure as precursor to a restorative service have been deleted

Periodontics – Revisions
D4266 guided tissue regeneration – resorbable… D4267 guided tissue regeneration – non-resorbable… Descriptors shortened to eliminate laundry list of steps / objectives

Periodontics – Substitute 2 for 1
Delete – D4271 free soft tissue graft procedure (including donor site surgery) Replace with – D4277 free soft tissue graft procedure (including donor site surgery), first tooth or edentulous tooth position in graft D4278 free soft tissue graft procedure (including donor site surgery), each additional contiguous tooth or edentulous tooth position in same graft site

Implant Services – Surgical Services
D6101 debridement of a periimplant defect and surface cleaning of exposed implant surfaces, including flap entry and closure D6102 debridement and osseous contouring of a periimplant defect; includes surface cleaning of exposed implant surfaces and flap entry and closure D6103 bone graft for repair of periimplant defect – not including flap entry and closure or, when indicated, placement of a barrier membrane or biologic materials to aid in osseous regeneration D6104 bone graft at time of implant placement – not including, when indicated, flap entry and closure, placement of a barrier membrane, or biologic materials to aid in osseous regeneration

Implant Services - Abutments
D6051 interim abutment Includes placement and removal. A healing cap is not an interim abutment. D6056 prefabricated abutment – includes modification and placement …Modification of a prefabricated abutment may be necessary… D6057 custom fabricated abutment – includes placement …Created by a laboratory process, specific for an individual application…

Implant Codes Single Crowns Implant D6010 Abutment prefabricated D6056 custom D6057 Crown D r 6094 titanium

Implant Codes If no abutment… Implant D6010 Crown implant supported D

Implant Codes Fixed Bridge Implant 6010 Abutment D Retainer D or D6194 (titanium) Pontic prostho code D If no abutment Retainer D

Implant Codes Implant/ Abutment Supported Removable Complete D6053 Partial D6054 Fixed Complete D6078 Partial D6079

Implant Codes Examples: Full Denture with Locators Implant D6010 Prefabricated abutment D6056 Removable denture D6053 All on Four Diem Implant D6010 Prefabricated abutment D6056 Fixed denture D6078 If connecting bar is utilized D6055 changed to cover implant or abutment supported

Prosthodontics, fixed – Related changes
Category of service descriptor added Fixed partial denture prosthetic procedures include routine temporary prosthetics. When indicated, interim or provisional codes should be reported separately Two revisions to reflect the added descriptor D6253 provisional pontic – further treatment or completion of diagnosis necessary prior to final impression ...Not to be used as a temporary pontic for routine prosthetic fixed partial dentures. D6793 provisional retainer crown – further treatment or completion of diagnosis necessary prior to final impression …Not to be used as a temporary retainer crown for routine prosthetic fixed partial dentures. No Notes

Prosthodontics, fixed – Deletions
Prompted by removing time criteria from “provisional” descriptors; duplication of codes in restorative category D6254 interim pontic D6795 interim retainer crown Prompted by duplication of codes in restorative category D6970 post and core in addition to fixed partial denture retainer, indirectly fabricated D6972 prefabricated post and core in addition to fixed partial denture retainer D6973 core buildup for retainer; including any pins D6976 each additional indirectly fabricated post – same tooth D6977 each additional prefabricated post – same tooth

Oral & Maxillofacial Surgery –
Related revision and addition – D7951 sinus augmentation with bone or bone substitutes via a lateral open approach The augmentation of the sinus cavity to increase alveolar height for reconstruction of edentulous portions of the maxilla. This procedure is performed via a lateral open approach. This includes obtaining the bone or bone substitutes. Placement of a barrier membrane if used should be reported separately. D7952 sinus augmentation via a vertical approach The augmentation of the sinus to increase alveolar height by vertical access through the ridge crest by raising the floor of the sinus and grafting as necessary. This includes obtaining the bone or bone substitutes. No Notes

Oral & Maxillofacial Surgery –
One addition to accommodate procedure’s growing use D7921 collection and application of autologous blood concentrate product No Notes

Adjunctive General Services – 1 and 1
Addition D9975 external bleaching for home application, per arch; includes materials and fabrication of custom trays Revision D9972 external bleaching – per arch – performed in office No Notes

Preventing Claim Form Errors
How to prevent various types of claim coding errors Unintended errors are most often caused by misunderstanding or misinformation Situations that can be avoided with knowledge Errors can be on the claim submission prepared by a dentist or practice staff Some arise when the claim is adjudicated by the third-party payer. Intentional errors are never acceptable.

What are the right codes for dental claims?
Primary code sources for dental claims are: CDT Manual containing the Code on Dental Procedures and Nomenclature (CDT Code) Dental Coding Made Simple containing – Tooth numbers and letters for permanent, primary and supernumerary teeth Numeric quadrant codes Provider specialty codes No notes

Avoiding procedure code errors
The first question to ask – Am I using the current version of the CDT Code? HIPAA says use the version of the CDT Code in effect on the date of service. For example, if the service is provided on July 1, 2013 use the version of the CDT Code published in CDT 2013. No notes

The second question to ask is – Have I selected the appropriate code for the service provided? When determining what procedure code to use please consider the complete entry – nomenclature and descriptor – printed in the current CDT manual. Some software and publications truncate nomenclatures and exclude descriptors. No notes

No code describing a procedure?
“unspecified… procedure by report” (Dnn99) codes are: For those situations where, in the opinion of the dentist none of the entries in the CDT Code accurately describe the services provided the patient In each category of dental services except Preventive. If you can’t find an applicable CDT Code, the only alternative is an “unspecified … procedure, by report” code

Suppose you reported either (or both) of the following procedures on a claim: D0160 detailed and extensive oral evaluation – problem focused, by report D2999 unspecified restorative procedure, by report The question to ask is – I used a “by report” code, have I included a narrative? No notes

“…by report” – What to say
A clear and concise narrative that includes: Clinical condition of the oral cavity Description of the procedure performed Specific reasons why extra time or material was needed How new technology enabled procedure delivery Any specific information required under a participating provider contract No Notes

“…by report” – What to say
A third-party payer is likely to return the entire claim if the narrative is missing. Even when the narrative is present you may be asked for additional information. No notes

New codified data – starting in 2012
Diagnosis – up to four may be reported for each procedure on a claim Reporting is discretionary May be reported on the HIPAA standard electronic dental claim and the ADA’s paper claim form Codes used are in the public domain ICD-9-CM (now) ICD-10-CM (later ) This information is required when the diagnosis may have an impact on the adjudication of the claim in cases where specific dental procedures may minimize the risks associated with the connection between the patient’s oral and systemic health conditions.

Coding for Reimbursement
Question – What procedure codes have the best chance of reimbursement? Answer – Codes for procedures that are covered by the patient’s dental benefit plan BUT Your treatment plan should be based on the patient’s clinical needs, not on covered procedures No Notes

Coding for Reimbursement
Facts of Life – Not all procedures are covered Some have annual or lifetime limitations Limitations and exclusions can vary between different plans offered by the same company HIPAA only requires that a payer accept a valid procedure code for processing HIPAA does not require that there be a payment for every procedure in the CDT Code No notes

Determining the date of service
When there is a single code for a procedure that requires multiple appointments (e.g., an immediate denture) how do I determine what the date of service should be? ADA policy for fixed and removable prosthetic cases encourages third party payers to use date of impression as date of service Some state laws & third party processing policies and contract provisions specify completion date as the date of service

Determining the date of service
Weigh all these factors when determining date of service reported for the procedure code Be consistent and compliant with policy, regulations and contract provisions Remember, ADA policy is aspirational, but requires inclusion in legislation or regulation to have any authority in a given jurisdiction No notes

Claim Coding Confusion
No notes

Examples of confusion –
There are many reasons why a dentist or practice staff may be unsure about the procedure code to use – e.g., Infrequent delivery of the procedure Conflicting information from peers or third-party payers Examples that follow are based on questions posed to ADA staff Guidance is based on the published procedure code nomenclatures and descriptors No notes

Consultation – or – Oral Evaluation?
When is it appropriate to report a consultation (D9310) instead of an evaluation (e.g., D0140)? A consultation occurs when Dentist A refers a patient to Dentist B for an opinion or advice on a particular problem Dentist A would report the appropriate oral evaluation code Dentist B would report the consultation code D9130. No notes

Periodic and Periodontal Evaluations
During a periodic oral evaluation the patient showed signs and symptoms of periodontal disease - and received a complete periodontal evaluation. May both evaluations be reported? Only the D0180 is reported It includes all components of a periodic evaluation, and adds additional requirements for periodontal charting and the evaluation of periodontal conditions No notes

Codes Limited to Dental Specialties?
Is reporting the ‘comprehensive periodontal evaluation’ (D0180) limited to Periodontists? D0180 is not limited to Periodontists All dental procedure codes are available to any practitioner providing service as permitted by state law No notes

Panoramic + Bitewings = “FMX?”
Are a panoramic film and bitewings considered a full mouth series of radiographs? No – a full mouth series (aka FMX) is defined in the descriptor of “D0210 intraoral, complete series…” “A set of intraoral radiographs usually consisting of 14 to 22 periapical and posterior bitewing images intended to display the crowns and roots of all teeth, periapical areas and alveolar bone crest.” No notes

Panoramic + Bitewings = “FMX?”
Third-party payers sometimes bundle claims for panoramic and bitewing (or periapical) images and calculate reimbursement using D0210 fees The ADA considers this a potentially fraudulent practice that should be appealed because: D0210 reimbursement is likely to be less than amounts paid for panoramic and other images Bundled payment could lead to denial of a later D0210 claim due to plan limitations/exclusions Records of services rendered will be inaccurate No notes

Product vs. Procedure Our office recently purchased a VelScope – what procedure code applies to its use? Procedure codes are not product or brand-name specific Devices such as the VelScope may be used in the delivery of procedures such as: D0431 adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures No notes

More difficult & time consuming
What code is used to document a difficult prophylaxis, or any procedure that requires more time than usual? There are no separate procedure codes that reflect the degree of difficulty or additional time required for operative dental procedures Existing procedure codes (e.g., D1110 prophylaxis – adult) are used to document the service No notes

Occlusal pits and fissures
When mechanical enlargement of occlusal pits and fissures is performed in conjunction with placement of a dental sealant, this preparation step is not reported separately The reason is the “D1351 sealant – per tooth” descriptor includes the preparation step Mechanically and/or chemically prepared enamel surface sealed to prevent decay. Sealants are usually applied when there is no decay No notes

Occlusal pits and fissures with decay - 1
There is a continuum of procedures related to pits and fissures When decay that does not extend into the dentin is present another procedure code is appropriate D1352 preventive resin restoration in a moderate to high caries risk patient – permanent tooth Conservative restoration of an active cavitated lesion in a pit or fissure that does not extend into dentin; includes placement of a sealant in any radiating non-carious fissures or pits. No notes

Occlusal pits and fissures with decay - 2
The continuum ends with a third procedure code that is appropriate when decay extends into the dentin D2391 resin-based composite – one surface, posterior Used to restore a carious lesion into the dentin or a deeply eroded area into the dentin. Not a preventive procedure. No notes

Prophylaxis + Scaling & Root Planing (SRP)
Can D1110 (adult prophylaxis) and D4342 (scaling and root planing one to three teeth) be reported on the same date of service? There is nothing in either codes’ nomenclature or descriptor that says these two cannot be delivered to the patient on the same day However, provisions of many benefit plans do not allow payment of benefits for these procedures when reported on the same date of service So, it is proper to record and report both procedures if performed on the same date, but not a guarantee of payment. Benefit plan cannot require that the dentist report this in a different manner than performed.

How may I report local anesthesia as a separate procedure?
“D9215 local anesthesia in conjunction with operative or surgical procedures” is the procedure code for separate reporting Benefit plan limitations and exclusions may preclude separate reimbursement for local anesthesia Participating providers are likely unable to bill patients when anesthesia is not reimbursed No notes

Two 2-Surface Restorations on Same Tooth
How do I report two separate 2-surface restorations on the same tooth? Carriers advise me to report a MO amalgam and a DO amalgam as a MOD restoration Report the procedures as performed, using D2150 twice – once for the MO and the second for the DO – on the same tooth Some plans limit coverage when the same surface is involved more than once on the same date, and may apply an alternate benefit based on the fee for a single restoration No notes

Lasers I recently purchased a laser and have not found any “laser” codes in the Code on Dental Procedures and Nomenclature The CDT Code is procedure based The service is documented with the procedure code that is appropriate for the actual procedure performed No notes

Crown materials What procedure code is used to document a porcelain fused to zirconium crown? The available procedure code is “D2740 crown – porcelain/ceramic substrate.” How is a porcelain fused to titanium crown reported as the only code is “D2794 crown – titanium” D2794 is the only titanium crown procedure code available and should be used for all varieties of titanium crowns No notes

IRM – Sedative or Palliative?
Is placement of IRM (Intermediate Restorative Material) a protective restoration, or a palliative, procedure? Either procedure is applicable depending on the clinical condition D2940 (protective restoration) is used for multiple reasons, including pain relief D9110 (palliative treatment) is only for emergency treatment of dental pain Only one of the two codes is used to document placement when the patient presents

Unfinished procedures
How is the doctor to report a situation where a restorative (or any other) procedure is started but not finished? The current version of the CDT Code does not contain codes for procedures that are started but not completed One exception – D3332 incomplete endodontic therapy; inoperable, unrestorable or fractured tooth For other situations an unspecified procedure, by report code (e.g., "D2999 unspecified restorative procedure, by report") may be used Note: the exception is for the instance when it is not possible to complete the endo.

Endodontic access restoration
An access cavity was made through a crown for endodontic treatment. What procedure code is appropriate to report sealing an endodontic access cavity? There is no code that specifically refers to placement of a restoration to seal an endodontic access cavity Appropriate restorative codes may be used to report the final sealing of an access cavity Or, an “unspecified…procedure, by report” code may be considered (e.g., D2999 unspecified restorative procedure, by report)

Debridement and Evaluations
Can I report a full mouth debridement – D4355 – on the same day as a comprehensive oral or periodontal evaluation? Yes, as there is no language in the D4355 descriptor that precludes the reporting of any other procedures on the same date of service However, dental benefit plans may exclude or limit reimbursement for the other services (e.g., D0150; D0180) when performed on the same day

Implant Pontics When reporting a fixed partial denture placed on implants, how do I report a pontic? There are no pontic codes in the CDT Code’s Implant Services category Pontic codes in the Prosthodontics, fixed category are used for both fixed partial and implant supported dentures All pontic codes begin with D62xx and are used with the appropriate Implant or FPD retainer codes

Partial extraction Is there a code for a partial extraction? The doctor removed most of the tooth, but was unable to remove the entire root and the patient was referred to an oral surgeon immediately The only partial extraction code is “D7251 coronectomy-intentional partial tooth removal” Used for a specific situation – when a neurovascular complication is likely if the entire impacted tooth is removed In all other cases, use code “D7999 unspecified oral surgery procedure, by report”

Orthodontic procedure codes – which one?
I do not understand how to code orthodontic procedures as there are very few codes, and most of the treatments are very complicated First - determine the patient’s stage of dentition, as defined in the Orthodontics category of service descriptor Second – plan the type of orthodontic treatment – limited, interceptive or comprehensive – as described in the subcategory descriptors Third – select the dentition specific procedure code in the applicable treatment subcategory of service Use D8670 to report periodic treatment visits

Clear aligners What is the code for clear aligners such as ClearCorrect™, Invisalign® or Red White & Blue ®? There is no unique procedure code for such devices Orthodontic services are documented based on the practitioner’s patient diagnosis and treatment plan Existing dentition/treatment based procedure codes are applicable to orthodontic services that involve clear aligners

When a claim is denied or rejected

When a claim is denied or rejected…
“The existence of a dental procedure code does not mean that the procedure is a covered or reimbursed benefit…” When would claim denial or rejection suggest misuse or interpretation of the CDT Code? Quote from the CDT manual preface – in every edition from CDT-1 onward Dental benefit plan coverage varies Not all possible services are covered Implants are one example of procedure not covered by benefit plan “Misuse” or “interpretation” refer to actions such as Bundling separate procedures into one so that reimbursement is reduced Applying a different nomenclature to a valid procedure code HIPAA misconception Since the Code is a named federal standard all procedures must be covered Payers must provide reimbursement for any valid procedure code

What does HIPAA say? Payer must accept valid procedure code for processing Payer does not have to base payment on procedure code reported Contract provisions (e.g., limitations and exclusions) may be applied Denial is possible under HIPAA What does HIPAA say? Procedure code reported must be valid for date of service and payer must accept valid code for processing Nothing about a payer’s claim adjudication process (e.g., policies, benefit limitations & exclusions) Denial is possible under HIPAA What HIPAA says A standard electronic dental claim may only contain procedures in the Code A dentist must submit the procedure code that is valid on the date of service A payer may not refuse to accept for processing a claim with a valid procedure code A payer’s benefit plan design and adjudication policies apply when processing a claim The CDT manual’s statement is consistent with HIPAA

What does the ADA say… OK: payer applies benefit plan limitations & exclusions – and says so e.g., plan does not cover any restorative procedure delivered on the same day a D4355 is reported Not OK: Payer ignores procedure code’s nomenclature or descriptor e.g., payer states that diagnostic radiographs are part of the D3310 procedure and cannot be reported separately Payer implication that dentist reported incorrect procedure on claim Claim with valid procedure code may be denied when based on Benefit plan limitations and exclusions Provisions of a participating provider contract Such denial would not be “interpretation” or “misuse” The Explanation of Benefit (EOB) document should make payer’s action clear Denial based on benefit plan design Procedure codes reported by dentist were valid When the EOB does not make payer action clear Patient and dentist receive an incomplete or misleading explanation Dentist should report this to the ADA

Example - Core Buildups
You report D2950 (core buildup) and D2750 (PFM) on a claim But payer says core build ups are part of the crown procedure Payer is wrong from the CDT Code’s perspective But payer may make single reimbursement based on benefit plan design Dentist’s ability to balance bill is subject to participating provider contract, if any No Notes

Hypothetical examples of what is: OK Not OK Note: Each example is limited to the facts given for it Insurance carriers will adjudicate claims based on agreements they have in force with plan purchasers (generally employers or union groups). So long as the agreements meet legal muster in terms of, clarity, consistency, and compliance with applicable laws and regulations, they will not generally be susceptible to legal attack. Even with valid agreements there may be legal questions concerning interpretation and scope of language in certain instances.

OK or not OK? Not OK – you report D1110 and payer says report D1120 for reimbursement Patient is 13 with predominantly adult dentition and plan design sets 15 as adult age Payer is asking you to report wrong procedure BUT – OK for payer to accept D1110 and pay at D1120 based on plan design EOB should reflect what was submitted In this example the Payer wants the Dentist to report procedure based on benefit plan Dentist should report procedures accurately and truthfully Dentist should report such occurrences to the ADA EOB should note that Dentist reported procedure based on patients clinical condition Also note that adjudication based on different procedure due to plan limitation

OK or not OK? You report D0120, D1120 and D1208 Not OK –
Payer says that these are not separate procedures Payer says all three procedures are part of D0120 Not OK – Payer is redefining D0120 Payer may be “bundling” Example of situation that should be reported to the ADA Note: Some situations that appear to be bundling may not be Participating Dentist may have contractually agreed to accept single reimbursement for several procedures

EOB to patient shows different codes
OK or not OK? EOB to patient shows different codes Claim form: D0120 and D1110 EOB: D0120 and D1120 Message says these are the correct codes for child patient Not OK: payer implication that dentist reported incorrect prophylaxis procedure code Example of situation that should be reported to the ADA Payer EOB should acknowledge that reimbursement based on plan design

Contact ADA Member Service Center (MSC) to report problems
What can you do? Contact ADA Member Service Center (MSC) to report problems Payers using the CDT Code must be licensed License does not dictate how a code is paid Arbitrary payer action is ADA concern Reports enable ADA staff to address recurring issues with payers “Dental Coding Made Simple” contains procedure coding Q&A Prepared by Council on Dental Benefit Programs To assist Dentist decide appropriate procedure code for service provided Reflects feedback from members who encountered problems with claim submissions ADA Member Service Center is first point of contact Questions about the Code or its use Report possible third-party payer Code “interpretation” or “misuse” MSC staff will either answer question immediately or refer inquiry to the appropriate ADA agency for action e.g., Council on Dental Benefit Programs / Division of Legal Affairs Contact MSC by Toll-free number found on the ADA membership card; Direct dial ( ) Code is a copyrighted work owned by the ADA that is licensed for use to outside entities (e.g., third party payers) Copyright license does not control how the Code is used for claims adjudication License does prohibit changing Code nomenclatures or descriptors Payers licensed to use the Code must abide by the copyright license Actions that do not adhere to contractual obligations may represent Code misuse and are reason to seek redress Unlicensed use of the Code is aggressively pursued by the Legal Division Arbitrary payer action is an ADA concern Even if an objectionable use of the Code is not a license violation or illegal Member reports enable staff to address individual issues with payers As well as providing the means to determine, monitor and address patterns of payer actions

Preventing and Resolving Errors

Preventing and resolving CDT Code errors
Prevention is the best practice, which means – Any questions concerning proper coding should be addressed as the claim is being prepared There should be a quality review before submission Otherwise, procedure code errors are usually revealed when – The payer rejects a claim Or asks for additional information before processing

Error prevention If there is any question about the correct code when staff is preparing the claim – The first source of procedure coding guidance is information in the office: The current CDT Manual* The dentist’s knowledge and experience. (* To determine if a code is applicable to the service provided read the complete entry, code nomenclature and descriptor, plus any category or subcategory descriptor)

Error prevention The second source of procedure coding guidance is the ADA. By telephone to the Member Service Center – (800) By to

Error resolution Review returned or denied claims to ensure that the procedure codes reported are correct If there is a coding error, prepare and submit a corrected claim Errors should always be corrected, but will not always eliminate an accusation of fraud When there is no coding error, prepare an appeal if there are grounds to do so, as in the following two examples

Payer error that should be appealed - 1
The patient is age 13 with predominantly adult dentition and you report D1110 The payer says report D1120 for reimbursement because the benefit plan says an adult is age 15 or more Here the payer is ignoring the D1110 descriptor and asking that you report the wrong procedure code Coding for what you do is the only proper action, regardless of payer policies or reimbursement

Payer error that should be appealed - 2
You report D0120, D1120 and D1203 on a claim, but the payer says these are not separate procedures, they are all part of the D0120 The payer is ignoring the nomenclatures and descriptors of these discrete codes, and is redefining procedure code D0120 – such redefinition is a copyright violation The payer may also be “bundling” – a potentially fraudulent act Payers may benefit procedures in combination with others as part of their payment policies But they cannot claim that discrete procedures are actually part of others

What do the contracts say?
What are your patient’s benefit plan limitations and exclusions – e.g., “Child prophy” reimbursement through patient age 15 No more than two D4910s per calendar year Benefit plan design is determined by payer and purchaser Premium cost is a factor in determining richness of coverage ADA policy on benefit plan design is advisory, not regulatory These are examples of benefit plan limitations and exclusions that are not consistent with ADA policy (e.g., Age of Child)

What do the contracts say?
What are your participating provider contract provisions – e.g., dentist agrees to: Least expensive alternative treatment “LEAT” reimbursement Reimbursement based on Payer guidelines v. specific codes reported on claim Dentist who signs a participating provider contract is generally bound to its legally sound provisions Know what you are agreeing to before signing – ADA Contract Analysis Service Examples of participating provider contract provisions A dentist who signs a participating provider contract is generally bound to its legally sound provisions.

Part 8 – Claim Formats ADA Dental Claim Form
HIPAA Electronic Standard 837Dv5010 1500 Health Insurance Claim Form (Medical) No Notes

ADA Dental Claim Form 2001 – HOD adopts resolution that ADA paper claim form data content mirror the HIPAA standard electronic dental claim, as much as possible First revisions when HIPAA standard became effective in 2003 Additional changes when National Provider Identifier (NPI) implemented in 2006 Latest changes with implementation of revised HIPAA standard in 2012

Latest version effective July 2012
ADA paper claim form Latest version effective July 2012 Key change is ability to report diagnosis codes used on the revised HIPAA standard – 837Dv5010 Diagnosis codes are from ICD-9-CM and, as of 10/01/14, from ICD-10-CM Comprehensive ADA form completion instructions on ADA.org Complete completion instructions are in “Dental Coding Made Simple” For those using older versions of the paper claim form It is important to understand how the current form differs The current will likely prompt changes to your practice management software If questions arise after today Please have them call the Member Service Center for assistance Toll free number on the ADA membership card Non-members can call

ADA claim form – Diagnosis Codes
Diagnosis Code Pointer “Click” to display the captions for each of the arrows ICD-9-CM Diagnosis Code (at least one)

Coordinating the Benefits
Which payer is primary when both parents have coverage for the dependent patient? How may I handle coordination of benefits? Many companies use “the birthday rule” Attach copy of the other payer’s EOB to the secondary claim Many companies use “the birthday rule” to establish primacy of coverage Primary coverage comes from the insured whose birthday is earliest in the calendar year This “rule” is common practice but not legislation or regulation Note: In cases of divorced parents a court order may determine which parent has primary financial responsibility

Claims against medical benefits
Different form “1500” paper form or HIPAA electronic equivalent May be submitted by any dentist delivering service within scope of state licensure Different code sets CPT or HCPCS procedure codes and modifiers ICD-9-CM diagnosis codes Dentists who frequently submit claims to patient medical benefit plans Specialize in Oral and Maxillofacial Surgery Growing number of general dentists are submitting claims to patient medical benefit plans For services where appropriate e.g., treatment arising from auto accidents or other injuries Medical benefit claims differ from claims against dental benefit plans Claim format Data content

TMD service – dental v. medical
How do I file a dental or medical claim for a mandibular occlusal bite appliance? Dental – ADA Dental Claim Form with procedure “D7880 occlusal orthotic device, by report” Medical –‘1500’ form with CPT/HCPCS procedure codes and ICD-9-CM diagnosis codes: HCPCS - S8262 Mandibular orthopedic repositioning device, each ICD Temporomandibular joint disorders, unspecified “CLICK” to display the third bullet point (Medical) and its subpoints Dentists may file claims against a medical plan As long as he/she is acting within the scope of his/her licensure Claim against dental benefit plan - Use ADA Dental Claim Form or HIPAA electronic equivalent (837D) Report D7880 occlusal orthotic device, by report Claim against medical benefit plan - Use the 1500 paper form or HIPAA electronic equivalent (8737P) Report applicable CPT or HCPCS procedure codes and ICD-9 diagnostic codes - the following might be appropriate HCPCS - S8262 Mandibular orthopedic repositioning device, each ICD Temporomandibular joint disorders, unspecified

Medical benefits claim form
Information on the 1500 Health Insurance Claim Form, including completion instructions, can be found at: This is the medical benefit plan paper claim form Likely available from the same supplier you use for dental claim forms NUCC is the American Medical Association committee that maintains The paper form and its recommended completion instructions leads to the National Uniform Claim Committee’s web site HIPAA standard electronic medical claim submission format is 837P Your practice management software may need maintenance to create an 837P Check with your vendor to see what changes or upgrades may be needed

Medical claims for dental services
Not always an exact match between dental and medical procedure codes One or more medical procedure code modifiers may be necessary One primary ICD-9-CM diagnosis code required Additional ICD-9-CM codes as needed Tooth # and oral cavity area reported using codes published in Dental Coding Made Simple manual These are concepts to reinforce. Not always an exact match between dental and medical procedure codes One or more medical procedure code modifiers may be necessary One primary ICD-9 diagnosis code required Additional ICD-9 codes as needed Tooth # and oral cavity area reported using codes published in CDT manual

Medical coding sources
Procedures (CPT & HCPCS) National Dental Advisory Service - OR Webb Dental - OR Diagnosis codes (ICD-9-CM) icd9cm.chrisendres.com One part of ICD-9 has most codes applicable to dental procedures Digestive system section ( ) Codes related to the oral cavity ( ) Other sections of ICD-9 have codes applicable to a claim for dental services Injuries (800 series) Accidents (E series)

Other Cross Coding Sources
Dr. Charles Blair & Associates Warschaw Learning Institute (ADA CERP Recognized Provider) Nierman Practice Management - Cross Code Module

“What if / How do I” Coding Scenarios
Illustrates how the CDT Code is your tool for documentation Key principles: Dentist who treats the patient can best determine what procedures were performed. Use the procedure code that best reflects what you do. A dental benefit plan may not provide coverage for every procedure code. Answers given are intended to demonstrate possible combinations of codes Dentist who treats a patient can best determine what procedures were performed May not be the same as those discussed here. “Code what you do” is the fundamental rule to apply in all coding scenarios The Code is a tool to use for your documentation needs Existence of a procedure code does not mean the procedure is covered by the dental plan Exercises are not to be considered legal advice or a guarantee that individual payer contracts will follow this assistance. NOTE: Please do not consider the exercises to be legal advice or a guarantee that individual payer contracts will follow the examples.

Monitoring the patient’s condition
Two weeks ago - initial visit Patient with traumatically loosened teeth No treatment; return to monitor healing Today – return visit where dentist: Looked for any remaining mobility or bleeding Determined that clinical condition had improved Suggested patient use an athletic mouthguard Patient of record; 9 years of age; first presented two weeks ago Chief complaint of four loose upper front teeth Child had been hit in the mouth with a thrown baseball Mild bleeding around the involved teeth but no lacerations Four teeth were no more mobile than one millimeter each Dentist did not find the need to provide tooth stabilization No treatment other than radiographs plus visual & manual examination Suggested a softer diet for a week to ten days First visit two weeks ago did not involve any definitive treatment Only evaluation, diagnosis, consultation and recommendation Second visit today - child presented for follow-up visit where the dentist Re-assessed the area of the previously existing condition No deleterious findings whatsoever Suggested that the child acquire and use an athletic mouthguard when participating in sporting activity Second visit constitutes a follow-up appointment Serves as a re-evaluation opportunity Enables dentist to monitor healing progress of the involved injury site

Monitoring the patient’s condition
Consider: D0170 re-evaluation - limited, problem focused (established patient; not post-operative visit) For patients who require assessment or monitoring of an identified condition Code D0170 is the recommended procedure code to report During the first visit the dentist did not need to render additional services beyond Assessment, diagnosis and recommendations to parent and child Regimen dentist deems most appropriate to allow for optimal healing process Today’s visit was a follow-up to assess the healing process Not part of routine post-operative care (e.g., suture removal, recement of temporary)

Topical Fluoride Treatments
Three friends visit the dentist All have Topical Fluoride applied Each has it coded differently D0000? Topical Application… Can you match the procedure to the patient’s condition? Three friends, Manny, Moe & Jack, decided to visit their dentist together. They all had their teeth cleaned and checked Each one had fluoride varnish applied to their teeth at the end of the visit When they compared their statements afterward The dentist had used a different code for each one Can you match the code with the appropriate application?

Topical Fluoride Treatments
NOTE: D1208 is used for materials such as gels or foams, but NOT when the material is fluoride varnish Manny never had a cavity ? D1208 topical application of fluoride Moe has decay after years without a cavity ? D topical application of fluoride varnish NOTE: D1206 is applicable ONLY when the material is fluoride varnish; often used when decay or caries risk is being addressed SEPARATE “CLICKS” REQUIRED TO DISPLAY EACH ANSWER– QUESTION MARK DISAPPEARS AND IS REPLACED BY THE PROCEDURE CODE AND NOMENCLATURE Manny – In this instance ‘varnish’ is just another modality for the application of fluoride D1208 topical application of fluoride Moe – Recent history suggests high risk for caries with the presence of incipient decay. D topical application of fluoride varnish A therapeutic use of fluoride varnish that requires serial applications Each application procedure would be coded using D1206 Jack – Sensitive teeth and no caries or other problems D9910 application of desensitizing medicament This code does not specify which medicament is to be used. FDA has approved use of fluoride varnish for desensitization Jack has sensitive teeth ? D9910 application of desensitizing medicament

Longer than usual prophy?
Two appointments (one per arch) to remove heavy nicotine stains & calculus What procedure code would be used? D1110 prophylaxis – adult Nothing precludes reporting for each appointment needed to complete the procedure Descriptor does not stipulate duration, frequency or number of teeth being treated SEPARATE “CLICK” REQUIRED TO DISPLAY THE TEXT AFTER THE WORDS “WHAT PROCEDURE CODE WOULD BE USED?” Patient requires 2 hygienist appointments to remove heavy nicotine stains & calculus One arch per appointment What procedure code would be used? D1110 prophylaxis – adult Nothing precludes reporting for each appointment needed to complete the procedure Descriptor does not stipulate duration, frequency or number of teeth being treated Plan limitations may apply

Longer than usual prophy – fee?
Dentist sets procedure fee – not the Code Adjust fee for out of the ordinary cases (e.g., multiple appointments; unusual amount of time) Contracts may affect reimbursement Benefit plan limitations and exclusions Participating provider contract: set fee schedule; balance billing not allowed Dentist sets procedure fee Code does not prohibit adjusting a fee for out of the ordinary cases (e.g., multiple appointments; unusual amount of time) Contracts may affect reimbursement Benefit plan limitations and exclusions Participating provider contract: set fee schedule; balance billing not allowed

Fractured Tooth – After Hours Visit
On a day the office is closed the dentist fitted a polycarbonate temporary crown on #8 Fractured distal-incisal angle and missing a distal composite restoration When the office opens it’s your job to document this correctly Office visit on Saturday when practice normally closed On examination tooth #8 Appeared to have fractured the mesial incisal angle Lost a distal composite restoration The doctor removed enough tooth structure to fit and cement a polycarbonate temporary crown On Monday, it's your job to code this correctly - What will you do? D0140 limited oral evaluation – problem focused D2970 temporary crown (fractured tooth) D9440 office visit - after regularly scheduled hours

Temporary Crown on #8 Before After No Notes

Fractured Tooth – After Hours Visit
Code Selected Why ? D0140 limited oral evaluation – problem focused Patient presented with a specific problem D2970 temporary crown (fractured tooth) This procedure code applies when providing immediate protection for the fractured tooth D9440 office visit - after regularly scheduled hours Care was provided when the office was closed No Notes

Indirect Crowns Office CAD/CAM machine mills post & core, and crown
Doctor cements post & core and preps tooth for the all-ceramic crown How would you document the services? CAD/CAM machine milling an esthetic post and core Dentist will: Cement post and core Prepare the tooth for the final all-ceramic crown CAD/CAM machine will mill the all-ceramic crown How would these procedures be coded? CAD/CAM is another type of indirect restorative procedure The following codes apply D2952 post and core indirectly fabricated – in addition to crown D2740 crown – porcelain/ceramic substrate

Indirect Crowns Code Selected Why?
D2952 post and core indirectly fabricated – in addition to crown The post & core, and the crown, are separate procedures Code D2952 applies whether post and core is ceramic or metallic D2740 crown – porcelain/ceramic substrate No Notes

Indirect Crowns – Office CAD/CAM v. Lab
What would be different? Instead of milling these items in your office you contacted a dental lab to prepare a cast gold post and all-porcelain crown for you No Notes

Indirect Crowns – Office CAD/CAM v. Lab
Code Selected Why? D2952 post and core indirectly fabricated – in addition to crown Same codes are used because both procedures are indirect (i.e., prepared outside the patient’s mouth) These codes apply no matter where the post & core, or crown, are fabricated – in the dentist’s office or in a commercial laboratory D2740 crown – porcelain/ceramic substrate No Notes

D4910 vs D1110 on follow-up visit
Patient is on a three month recall schedule after periodontal therapy – but dental plan limits D4910 reimbursement to twice a year The dentist wonders how to legitimately secure reimbursement for services delivered to a patient

D4910 vs D1110 on follow-up visit
If the treating dentist determines that a patient’s periodontal health: Requires a D4910 procedure every three months Deliver procedure with the patient understanding that the plan will only provide coverage for two per year Can be maintained with a D4910 every six months, and be augmented with a periodic routine prophylaxis (D1110) in between Deliver and report those procedures

Multiple Restorations on Same Tooth
Patient’s radiographs show two teeth with decay that need immediate restoration Tooth #14 received a MO restoration that did not extend into the DO placed at the same time Tooth #19 had a buccal pit restoration and an MOD restoration placed during the same visit Composite resin was used for all the restorations How would you code for the procedures on this visit?

Code Selected / Why ? 14 D2392 resin-based composite – two surface, posterior Reported twice (MO and DO) 19 D2391 resin-based composite – one surface, posterior For the buccal pit D2393 resin-based composite – three surface, posterior For the MOD

Some dental plans limit reimbursement when the same tooth surface is involved (i.e. #14 in the scenario) on the same date Separate restorations may be recoded as a single multiple surface restoration (e.g., an MO and a DO to an MOD) The ADA says separate restorations on the same tooth should be reported individually Nothing in the CDT Code says separate reporting is wrong

What does “tooth bounded space” mean?
This term is used in the nomenclature of codes: D4210 and D4211 (gingivectomy/gingivoplasty) D4240 and D4241 (gingival flap) D4260 and D4261 (osseous surgery) Illustrations follow All six codes whose nomenclatures were revised as a result of defining a “tooth bounded space”

This is a tooth bounded space
One missing tooth - #5 Bounded by #4 and #6

This is a larger tooth bounded space
Two missing teeth - #s 19 and 20 Bounded by #s 18 and 21

These are two tooth bounded spaces –
Two missing teeth - #s 18 and 20 Two spaces – 1st bounded by #s 17 & 19 / 2nd by #s 19 & 21

Three appointment treatment plan
Periodontially compromised patient presents with: mandibular partial and supra-gingival calculus suspicious lesions and missing teeth (“X”) X Lower partial cemented into place by layers of super-gingival calculus Teeth not covered in a mass of calculus were covered with a dark brown veneer of coffee and tobacco residue. Doctor completed comprehensive evaluation that included Exploration for caries, evaluation of occlusion Documenting of periodontal probing depths, gingival attachment levels Risk factors for periodontal disease A head and neck examination (white keratinized patch in left retromolar pad area) Four posterior and two anterior periapicals Two bitewings on the left and one on the right side. Patient health history notes patient taking medication for Type II Diabetes, smokes and chief complaint was “bleeding gums” Patient has a full upper denture and lower removable partial denture, and is missing #17, 19, 21, 23, 24, 25,26, 30, 31 & 32 Bone loss around the remaining teeth ranged from 1-4 mm Subgingival calculus was still present Pocket depths were all measured at 4-7mm Furcation of #18 was probed at Class II. Gingiva exhibited generalized moderate hyperemia and was dark red in color Indicating chronic inflammation Dentist expects the fiery red outline of the partial would fade significantly before the next appointment if the denture was periodically removed and cleaned

3 appointment plan – 1st appointment
Gross removal of calculus and stain Complete evaluation (exam) 6 periapical and 3 bitewing radiographs Disaggregated transepithelial biopsy (brush) of white patch Dispense one 16 oz. bottle of Chlorhexidine Gluconate rinse Dentist recommended a two-part treatment plan Three appointments immediately to address oral hygiene (neglected brushing and flossing) and harmful habits A return in 12 months to evaluate the patient’s ability to care for himself Today’s appointment Gross removal of calculus and stain complete evaluation (exam) radiographs (6 PA & 3 BW) disaggregated transepithelial biopsy (brush) of white patch dispense one 16 oz. bottle of Chlorhexidine Gluconate rinse

D4355 full mouth debridement… D0150 comprehensive oral evaluation OR D0180 comprehensive periodontal evaluation D0220 intraoral periapical first film + D0230 intraoral periapical each additional…(5) + D0273 bitewings – three films D7288 brush biopsy… D9630 other drugs and/or medicaments, by report CONTENTS DISPLAY AUTOMATICALLY Coding for today’s appointment D4355 full mouth debridement to enable comprehensive evaluation and diagnosis D0150 (comprehensive evaluation) or D0180 (comprehensive perio evaluation) Note similarities and differences Either code is acceptable – user’s choice Emphasize that D0180 is not a specialist-only code D0220 (1st periapical) D0230 (next periapical) Report five times, once for each periapical D0230 (three bitewings) D7288 Note that there are 3 other biopsy codes Hard tissue Transepithelial/architecturally intact Non-transepithelial/disaggregated D9630, noting need to report by narrative

Could the periapicals and bitewings be coded as a full mouth series? NO – “fmx” defined in D0210 descriptor Follows FDA/ADA radiographic guidelines Added to the CDT Code effective January 1, 2009 As of January 1, 2009 the Code defines a full mouth series Based on ADA/FDA radiographic guidelines D0210 intraoral - complete series of radiographic images A radiographic survey of the whole mouth, usually consisting of periapical and posterior bitewing images intended to display the crowns and roots of all teeth, periapical areas and alveolar bone. Note: “FMX” or “full mouth series” are acronyms and terms that are not found in the Code See D0210 nomenclature (above) Also “panorex” is not a word found in the Code See D0330 panoramic film

3 appointment plan – 2nd appointment
Discuss risks of tobacco use and withdrawal program, plus prescription for nicotine patches Scaling and root planing of the lower right quadrant Anesthesia by non-injectable periodontal gel in the sulcus Irrigation of each sulcus with Chlorhexidine Gluconate rinse Dentist knew that non-surgical treatment would only go so far resolving the patient’s problems and Patient not a good candidate for surgery at this time Dentist recommended a conservative approach while patient addressed his other health issues Services rendered at 2nd appointment Discussion of tobacco use risks and contributory habits Design of a program to quit, along with a prescription for “The Patch” Scaling and root planning of the entire mouth Using a non-injectable periodontal gel in the sulcus for anesthesia Followed by irrigation of each sulcus with Chlorhexidine Gluconate rinse

3 appointment plan – 2nd appointment
D1320 tobacco counseling for control of dental disease D4342 periodontal scaling and root planing – one to three teeth per quadrant D9215 local anesthesia (optional) No code for sulcular irrigation, but consider: D4999 unspecified periodontal procedure, by report Coding for the 2nd appointment – D1320 tobacco counseling for control of dental disease D4342 (periodontal scaling and root planing –one to three teeth per quadrant Note there are three teeth and no teeth spaces are “unbounded” Local anesthesia may be reported separately if desired A separate code is available, D9215 Dental benefit plan may not provide separate reimbursement No code exists for sulcular irrigation D4999 might be used on a “by report” basis

3 appointment plan – 3rd appointment
Review progress on tobacco use cessation program and results of biopsy Scaling and root planing entire lower left quadrant Mandibular block anesthesia Placement of Atridox® antibacterial gel in each sulcus Services anticipated for third appointment Review of progress on tobacco use cessation program and results of biopsy Scaling and root planing of the entire lower left quadrant Using mandibular block anesthesia Followed by placement of Atridox antibacterial gel in each sulcus. How would you code for this appointment?

3 appointment plan – 3rd appointment
D1320 tobacco counseling (if needed) D4342 periodontal scaling & root planing – 1 to 3 teeth… D9211 regional block anesthesia D4381 localized delivery of antimicrobial agents…, by report CONTENTS DISPLAY AUTOMATICALLY Codes for 3rd appointment would be D1320 or nothing if not needed Note that the Code does state that this as a single use procedure Payers, dental or medical, might have a plan limitation D4341, noting that even though there are two separate bounded teeth spaces There are only three teeth that were treated in this quadrant D4381 for placement of Atridox Or other medicaments like Arrestin, Actisite or the Periochip D4381 is appropriate for these medicines because They utilize a controlled release mechanism This would exclude passive delivery mechanisms like irrigation. Some carriers will pay for D4381 on the same date of service as a D4341 or D4342 Only if the pocket depth is sufficient to hold the medicament. (4.5-5 mm minimum) Others will only pay D4381 after 10 to 14 days post-scaling and root planing Theory is that one should wait to see if the SRP engenders sufficient shrinkage To render the antibiotic usage moot

“Quadrant” procedure crossing the midline
Fixed partial denture replacing #s 23, 24, 25, & 26 4-5 mm pockets around #22 & 27 Flap surgery with open root planing of #s 22 and 27 X X X X Patient had a hockey accident as a 17 year-old that left him with a fixed partial denture replacing #’s 23, 24, 25, & 26. Patient brushed diligently but less regular with flossing and never bothered with flossing under the bridge Patient has 4-5 mm pockets around #22 & 27 Dentist recommended flap surgery with open root planing of these two teeth How would you code this visit?

“Quadrant” procedure crossing the midline
Space adjacent to #s 22 & 27 is a bounded space But not bounded in either quadrant Use the following code twice: D4261 osseous surgery (including flap entry and closure) - 1 to 3 contiguous teeth or tooth bounded spaces per quadrant 2ND BULLET POINT DISPLAYS AUTOMATICALLY Space adjacent to #s 22 & 27 is a bounded space But it is not bounded in either quadrant Use the following code twice: D4261 osseous surgery (including flap entry and closure) - 1 to 3 contiguous teeth or tooth bounded spaces per quadrant

Partial denture repair and extension
Existing maxillary partial denture #s12 & 13 missing, and #14 broken 3-part treatment plan Add prosthesis for 12 & 13 to the partial Full cast noble metal survey crown for 14 Must fit an existing clasp Additional clasp for retention on tooth 11 Jake is missing two teeth, #’s 12 & 13, and #14 was broken Jake’s plan: 3-part treatment plan Add prosthesis for 12 & 13 to the partial Full cast noble metal survey crown for 14 that must fit an existing clasp Additional clasp for retention on tooth #11

Partial denture repair and extension
D5650 add tooth to existing partial denture Report twice: once for #12 and again for #13 D2790 crown – full cast high noble metal Part 2 D2971 additional procedures to construct new crown under existing partial denture framework Part 3 D5660 add clasp to existing partial denture This is how Jake’s treatment could be coded Part 1 #12 - D5650 add tooth to existing partial denture #13 - D5650 add tooth to existing partial denture #14 - D2790 crown-full cast high noble metal Part 2 #14 - D2971 additional procedures to construct new crown Under existing partial denture framework Part 3 #11 - D5660 add clasp to existing partial denture

Fractured incisors + exposed pulp
Two fractured incisors One with exposed pulp Planned treatment: Root canal + pre-fabricated ceramic post Direct resin bonded restorations BULLETS AND ARROWS UNDER “PLANNED TREATMENT” DISPLAY AUTOMATICALLY Elwood had a pair of fractured incisors, with #9 showing the pulp. Two part treatment plan Root canal on #9 to precede restoration, with prefabricated ceramic post Direct resin bonded restorations Image courtesy of Quintessence Publishing - Change Your Smile, 2nd Edition, R. Goldstein

Fractured incisors + exposed pulp
D3310 anterior (excluding final restoration) D2999 unspecified restorative… For the prefabricated ceramic post D2335 resin-based composite - 4 or more surfaces or involving incisal angle (anterior) Report twice - two teeth are restored This is how Elwood’s procedures could be coded D3310 anterior (excluding final restoration) D2954 prefabricated post and core in addition to crown D2335 resin-based composite - 4 or more surfaces or involving incisal angle (anterior) [report twice] Note: D2954 is not the perfect fit for this procedure because no crown is planned and the final restoration is direct resin. D2999 could be used instead Either solutions will probably require a narrative to specify what was done / explain the final restorative plan

Two procedures on the same day
Limited pocketing on 2 teeth OK to report prophylaxis (e.g., D1110) and scaling & root planing (e.g., D4342) on the same date? Codes’ nomenclatures or descriptors do not preclude delivery or reporting on same date Dentist’s clinical judgment determines which services are appropriate and when they should be delivered Some third-party payer benefit plan limitations and exclusion do not cover services on same date SEPARATE “CLICK” REQUIRED TO DISPLAY TEXT IN 2ND AND 3RD BULLET POINTS Comprehensive exam showed no caries or other dental problems, but revealed - Generalized mild to moderate gingival inflammation with 6mm pocketing on the mesial of #19 and 4mm on the distal of #21. 7 vertical bitewings showed little bone involvement but did reveal subgingival calculus deposits & vertical loss in the area’s with deeper pockets After prophylaxis the dentist recommended that #19 and #21 would benefit from root planing Area anesthetized and root planed the teeth Dentist’s clinical judgment determines which services should be delivered and the applicable procedure codes to report on a claim D1110 prophylaxis – adult D4342 scaling and root planing - 1 to 3 teeth per quadrant There are no restrictions in nomenclatures or descriptors that preclude the use of either of these codes with the other Some third-party plans have policies that benefits cannot be paid for both of these procedures on the same date of service

Consultation – or an Oral Evaluation?
Oral surgeon has consultation referrals Use “problem-focused” exam code or the “consultation” code? A specialist may use any oral evaluation code or the consultation code D9310 Use one or the other, but not both on same day OK to use D9310 if other diagnostic services or treatment provided Other services reported separately SEPARATE “CLICKS” REQUIRED TO DISPLAY TEXT IN 2ND AND 3RD BULLET POINTS As of January 1, 2007 code D9310 was revised to make this code easier to understand. You may use this code for your consultation and use other diagnostic and treatment codes when you provide these services, even on the same day. Whether to use an evaluation code and which one to use depends on what you do Many specialty offices use the limited problem-focused exam when consulting for a specific problem Whether to use it instead of D9310 depends on the nature and scope of the evaluation and consultation Nothing in the Code precludes a specialist from using one of the other evaluation codes or performing the evaluation as part of a consultation But you should only use one or the other for the same patient on the same day

No code describing a procedure?
Unspecified, “by report” (Dnn99) procedure codes Use when there is no applicable procedure code Attached narrative should include: Treatment plan; supplementary information Then consider submitting a CDT Code change request form “unspecified … procedure, by report” codes are for those situations where, in the opinion of the dentist: None of the codes contained in the Code on Dental Procedures and Nomenclature accurately describe the services provided the patient “unspecified … procedure, by report” codes e.g., D2999 unspecified restorative procedure, by report Are included for each category of dental services With the exception of Preventive. A third-party payer may request additional documentation for certain procedures Regardless of the presence of the narrative “report”. When you submit a narrative, describe the procedure performed If applicable, include The necessity for extra time Use of new technology, etc. Include supplementary information that You feel will be helpful in determining benefits Which is required by the third party payer If a multi-page narrative is submitted Include the patient’s name on each page Staple all pages together

CDT Code Maintenance CDBP Code Advisory Committee
21 voting members from all sectors of the dental community 5 ADA, 5 Payer, 9 Dental Specialties, 1 AGD, 1 ADEA Reviews change requests & determines which to accept or decline Reasons for revising include: Changes in technology that led to new procedures not described in the Code To improve clarity and accuracy of nomenclature and descriptors To delete codes no longer needed. Requests for changes may be submitted by anyone: Individual dentists or practice staff, Study club, Dental specialty organizations, Dental companies or third-party payers It is not unusual for similar requests to be considered many times Council on Dental Benefit Programs has ADA Bylaws responsibility for maintenance

CDT Code Maintenance Process open to any interested party Questions?
Requests from dentists as well as ADA, payers, etc. Information about the process on-line Questions? Council on Dental Benefit Programs (CDBP) ADA member toll-free number or There are separate forms for procedure codes and for categories/sub-categories of service Change actions are: Addition / Revision / Deletion Process information on the Internet - ada.org/goto/dentalcode Timeline Request forms and completion instructions MS Word documents for download Complete and save at your office Return completed form via - Change request submission guidelines and evaluation criteria For assistance please contact the ADA Member Service Center Toll free number on the ADA membership card Non-members can call

before some closing comments
????? Your Questions ????? Ask for questions from the audience Please REPEAT the question for the sake of the audience members Who may not have heard the question If a question arises that you cannot answer Give the Member Service Center phone number ADA member toll free number on ID card For non-members: The MSC can be called at any time should other questions arise Today, we have: Learned the history of the Code and how changes are made Identified changes made to the Code, effective January 1, 2013 Reviewed previous major changes in the Code Increased knowledge of the Code through coding scenarios and the Q&A Now - Some additional related information before some closing comments

CDT 2013 Includes: The CDT Code
Illustrations of all additions, revisions, and deletions Alpha Index Sales and pricing set by ADA Department of Salable Materials Several differently priced packages are available Non-members pay 50% more. CDT manual contains – Preface (containing history and discussion of revision process) The Code, effective January 1, 2013 through December 31, 2013 Color-coded summary of all Code changes by category of service Alphabetical index to the Code CD-ROM Users Guide To order your copy, call or visit our on-line product catalogue at

CDT Code Check “App” for your iPhone, iPad or Android device
Portable resource for dentists and practice staff Contains every code in the CDT Manual To purchase – visit Apple iTunes store or Android Market and search “CDT Code Check”

Dental Coding Made Simple
Includes: Coding exercises and Q&A Comprehensive dental claim form completion instructions Tooth and oral cavity area code schemas Sales and pricing set by ADA Department of Salable Materials Several differently priced packages are available Non-members pay 50% more. Dental Coding Made Simple is a companion to the CDT Manual To order your copy, call or visit our on-line product catalogue at

ADA Seal of Acceptance Surveys show patients trust you – and use what you recommend

ADA Seal of Acceptance Designed to help consumers make informed decisions about safe and effective consumer products Product must undergo rigorous scientific review to ensure it meets ADA safety and effectiveness criteria For detailed information Professionals: ADA.org at Consumers: MouthHealthy.org at

Learn about member benefits at www.ada.org
ADA membership To join - call Learn about member benefits at Member Service Center ADA speaks as the recognized voice of more than 160,000 dentists nationwide Active ADA participation helps ensure dentistry’s future For membership information contact Member Service Center or visit the ADA’s web site As a member you help give the ADA strength to make your concerns count ADA has taken on insurance companies to help assure that They pay dentists what they promise and treat them fairly Ongoing ADA campaigns on oral cancer detection, community fluoridation, diabetes management Member benefits include: Patient education material, many now available in Spanish, that help you explain your services easily with reliable content developed through “real world” feedback and dental research JADA and ADA News helps keep you on top of the latest developments in dental research and issues affecting the profession Access members-only content on ADA.org ADA Member Service Center helps members navigate the information, resources and benefits of membership Use the “members-only” 800 number to get your questions answered

Montana Dental Association

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