Brought to you by… - Montana Dental Association

Report
Montana Dental Association
May 2, 2013
© 2012 American Dental Association, All Rights Reserved
1
Optimize your Practice:
Understanding the CDT Code
v.2013 (and More)
Prepared for you by the Council on Dental Benefit Programs
2
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
© 2012 American Dental Association, All Rights Reserved
3
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
© 2012 American Dental Association, All Rights Reserved
4
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
© 2012 American Dental Association, All Rights Reserved
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© 2012 American Dental Association, All Rights Reserved
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© 2012 American Dental Association, All Rights Reserved
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© 2012 American Dental Association, All Rights Reserved
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What is the CDT Code
Shorthand for the ADA’s Code on Dental
Procedures and Nomenclature
© 2012 American Dental Association, All Rights Reserved
9
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
© 2012 American Dental Association, All Rights Reserved
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Why a CDT Code?
• Purpose –
– 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
© 2012 American Dental Association, All Rights Reserved
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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.”
© 2012 American Dental Association, All Rights Reserved
12
Categories of Service
I.
Diagnostic
D0100D0999
VII.
Maxillofacial
Prosthetics
D5900D5999
II.
Preventive
D1000D1999
VIII.
Implant Services
D6000D6199
III.
Restorative
D2000D2999
IX.
Prosthodontics fixed
D6200D6999
IV.
Endodontics
D3000D3999
X.
Oral and
Maxillofacial
Surgery
D7000D7999
V.
Periodontics
D4000D4999
XI.
Orthodontics
D8000D8999
VI.
Prosthodontics –
removable
D5000D5899
XII.
Adjunctive
General Services
D9000D9999
© 2012 American Dental Association, All Rights Reserved
13
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 14-22 periapical and
posterior bitewing images…
Descriptor (description)
Narrative providing further definition and intended use of the
procedure; most but not all codes have a descriptor
© 2012 American Dental Association, All Rights Reserved
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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
© 2012 American Dental Association, All Rights Reserved
15
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
© 2012 American Dental Association, All Rights Reserved
16
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
© 2012 American Dental Association, All Rights Reserved
17
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
© 2012 American Dental Association, All Rights Reserved
18
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
© 2012 American Dental Association, All Rights Reserved
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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.
© 2012 American Dental Association, All Rights Reserved
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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
© 2012 American Dental Association, All Rights Reserved
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Preventive – One revision
Before change –
As revised –
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.
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
© 2012 American Dental Association, All Rights Reserved
22
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
© 2012 American Dental Association, All Rights Reserved
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Restorative – Highlighting 2 revisions
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.
No more arbitrary
time criteria!
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.
© 2012 American Dental Association, All Rights Reserved
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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
© 2012 American Dental Association, All Rights Reserved
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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.
© 2012 American Dental Association, All Rights Reserved
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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
© 2012 American Dental Association, All Rights Reserved
27
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
© 2012 American Dental Association, All Rights Reserved
28
Periodontics – Revisions
D4266 guided tissue regeneration –
resorbable…
D4267 guided tissue regeneration – nonresorbable…
• Descriptors shortened to eliminate laundry list
of steps / objectives
© 2012 American Dental Association, All Rights Reserved
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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
© 2012 American Dental Association, All Rights Reserved
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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
© 2012 American Dental Association, All Rights Reserved
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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…
© 2012 American Dental Association, All Rights Reserved
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Implant Codes
Single Crowns
Implant D6010
Abutment
prefabricated D6056
custom
D6057
Crown D6058-64 0r 6094 titanium
© 2012 American Dental Association, All Rights Reserved
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Implant Codes
If no abutment…
Implant D6010
Crown implant supported D6065-67
© 2012 American Dental Association, All Rights Reserved
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Implant Codes
Fixed Bridge
Implant 6010
Abutment D6056-57
Retainer D6068-6073 or D6194 (titanium)
Pontic prostho code D6240-6242
If no abutment
Retainer D6075-6077
© 2012 American Dental Association, All Rights Reserved
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Implant Codes
Implant/ Abutment Supported
Removable
Complete D6053
Partial
D6054
Fixed
Complete D6078
Partial
D6079
© 2012 American Dental Association, All Rights Reserved
36
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
© 2012 American Dental Association, All Rights Reserved
37
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.
© 2012 American Dental Association, All Rights Reserved
38
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
© 2012 American Dental Association, All Rights Reserved
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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.
© 2012 American Dental Association, All Rights Reserved
40
Oral & Maxillofacial Surgery –
• One addition to accommodate procedure’s
growing use
D7921 collection and application of
autologous blood concentrate
product
© 2012 American Dental Association, All Rights Reserved
41
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
© 2012 American Dental Association, All Rights Reserved
42
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
© 2012 American Dental Association. All Rights Reserved
43
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
©©2012
2012 American Dental Association. All Rights Reserved
44
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.
©©2012
2012 American Dental Association. All Rights Reserved
45
Avoiding procedure code errors
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.
©©2012
2012 American Dental Association. All Rights Reserved
46
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.
©©2012
2012 American Dental Association. All Rights Reserved
47
Avoiding procedure code errors
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?
©©2012
2012 American Dental Association. All Rights Reserved
48
“…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
©©2012
2012 American Dental Association. All Rights Reserved
49
“…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.
©©2012
2012 American Dental Association. All Rights Reserved
50
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 - 2014)
©©2012
2012 American Dental Association. All Rights Reserved
51
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
©©2012
2012 American Dental Association. All Rights Reserved
52
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
©©2012
2012 American Dental Association. All Rights Reserved
53
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
©©2012
2012 American Dental Association. All Rights Reserved
54
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
© 2012 American Dental Association, All Rights Reserved
55
Claim Coding Confusion
©©2012
2012 American Dental Association. All Rights Reserved
56
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
©©2012
2012 American Dental Association. All Rights Reserved
57
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.
©©2012
2012 American Dental Association. All Rights Reserved
58
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
©©2012
2012 American Dental Association. All Rights Reserved
59
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
©©2012
2012 American Dental Association. All Rights Reserved
60
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.”
©©2012
2012 American Dental Association. All Rights Reserved
61
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
©©2012
2012 American Dental Association. All Rights Reserved
62
Product vs. Procedure
Our office recently purchased a VelScope –
what procedure code applies to its use?
> Procedure codes are not product or brandname 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
©©2012
2012 American Dental Association. All Rights Reserved
63
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
©©2012
2012 American Dental Association. All Rights Reserved
64
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
©©2012
2012 American Dental Association. All Rights Reserved
65
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.
©©2012
2012 American Dental Association. All Rights Reserved
66
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.
©©2012
2012 American Dental Association. All Rights Reserved
67
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
©©2012
2012 American Dental Association. All Rights Reserved
68
Local anesthesia
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
©©2012
2012 American Dental Association. All Rights Reserved
69
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
©©2012
2012 American Dental Association. All Rights Reserved
70
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
©©2012
2012 American Dental Association. All Rights Reserved
71
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
©©2012
2012 American Dental Association. All Rights Reserved
72
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
©©2012
2012 American Dental Association. All Rights Reserved
73
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
©©2012
2012 American Dental Association. All Rights Reserved
74
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)
©©2012
2012 American Dental Association. All Rights Reserved
75
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
©©2012
2012 American Dental Association. All Rights Reserved
76
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
©©2012
2012 American Dental Association. All Rights Reserved
77
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”
©©2012
2012 American Dental Association. All Rights Reserved
78
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
©©2012
2012 American Dental Association. All Rights Reserved
79
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
©©2012
2012 American Dental Association. All Rights Reserved
80
When a claim is denied or rejected
© 2012 American Dental Association. All Rights Reserved
81
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?
©©2012
2012 American Dental Association. All Rights Reserved
82
When a claim is denied or rejected…
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
©©2012
2012 American Dental Association. All Rights Reserved
83
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
©©2012
2012 American Dental Association. All Rights Reserved
84
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
©©2012
2012 American Dental Association. All Rights Reserved
85
When a claim is denied or rejected…
Hypothetical examples of what is:
> OK
> Not OK
Note: Each example is limited to the facts
given for it
©©2012
2012 American Dental Association. All Rights Reserved
86
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
©©2012
2012 American Dental Association. All Rights Reserved
87
OK or not OK?
You report D0120, D1120 and D1208
> 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”
©©2012
2012 American Dental Association. All Rights Reserved
88
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
©©2012
2012 American Dental Association. All Rights Reserved
89
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
©©2012
2012 American Dental Association. All Rights Reserved
90
Preventing and Resolving Errors
©©2012
2012 American Dental Association. All Rights Reserved
91
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
©©2012
2012 American Dental Association. All Rights Reserved
92
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)
©©2012
2012 American Dental Association. All Rights Reserved
93
Error prevention
The second source of procedure coding
guidance is the ADA.
• By telephone to the Member Service
Center – (800) 621-8099
• By email to [email protected]
©©2012
2012 American Dental Association. All Rights Reserved
94
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
©©2012
2012 American Dental Association. All Rights Reserved
95
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
©©2012
2012 American Dental Association. All Rights Reserved
96
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
©©2012
2012 American Dental Association. All Rights Reserved
97
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
© 2012 American Dental Association, All Rights Reserved
98
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
© 2012 American Dental Association, All Rights Reserved
99
Part 8 – Claim Formats
ADA Dental Claim Form
HIPAA Electronic
Standard 837Dv5010
1500 Health
Insurance Claim
Form (Medical)
©©2012
2012 American Dental Association. All Rights Reserved
100
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
©©2012
2012 American Dental Association. All Rights Reserved
101
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
©©2012
2012 American Dental Association. All Rights Reserved
102
ADA claim form – Diagnosis Codes
Diagnosis Code Pointer
ICD-9-CM Diagnosis
Code (at least one)
©©2012
2012 American Dental Association. All Rights Reserved
103
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
© 2012 American Dental Association, All Rights Reserved
104
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
© 2012 American Dental Association, All Rights Reserved
105
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-9 - 524.60 Temporomandibular joint disorders,
unspecified
© 2012 American Dental Association, All Rights Reserved
106
Medical benefits claim form
Information on the
1500 Health
Insurance Claim
Form, including
completion
instructions, can be
found at:
www.nucc.org
©©2012
2012 American Dental Association. All Rights Reserved
107
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
© 2012 American Dental Association, All Rights Reserved
108
Medical coding sources
• Procedures (CPT & HCPCS)
– National Dental Advisory Service www.ndas.com OR 800-669-3337
– Webb Dental - www.webbdental.com OR 877628-3366
• Diagnosis codes (ICD-9-CM)
– icd9cm.chrisendres.com
– www.icd9coding.com
© 2012 American Dental Association, All Rights Reserved
109
Other Cross Coding Sources
• Dr. Charles Blair & Associates
– http://www.drcharlesblair.com/
– 866.858.7596
• Warschaw Learning Institute (ADA CERP Recognized
Provider)
– http://www.warschawlearninginstitute.com/showPage.
php?pg=DentaltoMedicalCrossCodingCourse
• Nierman Practice Management - Cross Code
Module
– http://www.dentalcrosscode.com/
© 2012 American Dental Association, All Rights Reserved
110
“What if / How do I” Coding Scenarios
• Illustrates how the CDT
Code is your tool for
documentation
• Key principles:
NOTE: Please do not consider the
exercises to be legal advice or a
guarantee that individual payer
contracts will follow the examples.
– 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.
© 2012 American Dental Association, All Rights Reserved
111
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
© 2012 American Dental Association, All Rights Reserved
112
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
© 2012 American Dental Association, All Rights Reserved
113
Topical Fluoride Treatments
Three friends visit the dentist
All have Topical Fluoride applied
Each has it coded differently
Can you match the
procedure to the
patient’s condition?
©©2012
2012 American Dental Association. All Rights Reserved
114
Topical Fluoride Treatments
Manny never had a cavity
?
NOTE: D1208 is used for
materials such as gels or
foams, but NOT when the
material is fluoride varnish
D1208 topical application of fluoride
Moe has decay after years without a cavity
?
D1206 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
Jack has sensitive teeth
?
D9910 application of desensitizing medicament
©©2012
2012 American Dental Association. All Rights Reserved
115
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
© 2012 American Dental Association, All Rights Reserved
116
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
© 2012 American Dental Association, All Rights Reserved
117
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
© 2012 American Dental Association, All Rights Reserved
118
Temporary Crown on #8
Before
After
© 2012 American Dental Association, All Rights Reserved
119
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
Care was provided when
the office was closed
D9440 office visit - after
regularly scheduled hours
©©2012
2012 American Dental Association. All Rights Reserved
120
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?
© 2012 American Dental Association, All Rights Reserved
121
Indirect Crowns
Code Selected
Why?
D2952 post and • The post & core, and the
core indirectly
crown, are separate
fabricated – in
procedures
addition to crown
• Code D2952 applies whether
D2740 crown –
post and core is ceramic or
porcelain/ceramic
metallic
substrate
©©2012
2012 American Dental Association. All Rights Reserved
122
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
© 2012 American Dental Association, All Rights Reserved
123
Indirect Crowns – Office CAD/CAM v. Lab
Code Selected
Why?
D2952 post and • Same codes are used
core indirectly
because both procedures are
fabricated – in
indirect (i.e., prepared
addition to crown
outside the patient’s mouth)
D2740 crown –
• These codes apply no matter
porcelain/ceramic where the post & core, or
substrate
crown, are fabricated – in the
dentist’s office or in a
commercial laboratory
©©2012
2012 American Dental Association. All Rights Reserved
124
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
© 2012 American Dental Association, All Rights Reserved
125
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
© 2012 American Dental Association, All Rights Reserved
126
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?
© 2012 American Dental Association, All Rights Reserved
127
Multiple Restorations on Same Tooth
Tooth
#
14
19
19
Code Selected /
Why ?
D2392 resin-based composite – two surface,
posterior
 Reported twice (MO and DO)
D2391 resin-based composite – one surface,
posterior
 For the buccal pit
D2393 resin-based composite – three surface,
posterior
 For the MOD
©©2012
2012 American Dental Association. All Rights Reserved
128
Multiple Restorations on Same Tooth
• 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
© 2012 American Dental Association, All Rights Reserved
129
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
© 2012 American Dental Association, All Rights Reserved
130
This is a tooth bounded space
One missing tooth - #5
Bounded by #4 and #6
© 2012 American Dental Association. All Rights Reserved
131
This is a larger tooth bounded space
Two missing teeth - #s 19 and 20
Bounded by #s 18 and 21
© 2012 American Dental Association. All Rights Reserved
132
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
© 2012 American Dental Association, All Rights Reserved
133
Three appointment treatment plan
• Periodontially compromised patient presents
with:
– mandibular partial and supra-gingival calculus
– suspicious lesions and missing teeth (“X”)
X
X
X
X
X
X
X X X X
© 2012 American Dental Association, All Rights Reserved
134
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
© 2012 American Dental Association, All Rights Reserved
135
3 appointment plan – 1st appointment
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
© 2012 American Dental Association, All Rights Reserved
136
3 appointment plan – 1st appointment
• 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
© 2012 American Dental Association, All Rights Reserved
137
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
© 2012 American Dental Association, All Rights Reserved
138
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
© 2012 American Dental Association, All Rights Reserved
140
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
© 2012 American Dental Association, All Rights Reserved
141
“Quadrant” procedure crossing the midline
Fixed partial denture
replacing #s 23, 24, 25,
& 26
> 4-5 mm pockets around
#22 & 27
X XXX
Flap surgery with open
root planing of #s 22
and 27
© 2012 American Dental Association. All Rights Reserved
142
“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
© 2012 American Dental Association, All Rights Reserved
143
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
© 2012 American Dental Association, All Rights Reserved
144
Partial denture repair and extension
• Part 1
– 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
© 2012 American Dental Association, All Rights Reserved
145
Fractured incisors + exposed pulp
•Two fractured incisors
– One with exposed pulp
Planned
treatment:
• Root canal +
prefabricated
ceramic post
Image courtesy of Quintessence Publishing - Change Your Smile, 2nd
• Direct resin
bonded
Edition, R. Goldstein restorations
© 2012 American Dental Association, All Rights Reserved
146
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
© 2012 American Dental Association, All Rights Reserved
147
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
© 2012 American Dental Association, All Rights Reserved
148
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
© 2012 American Dental Association, All Rights Reserved
149
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
© 2012 American Dental Association, All Rights Reserved
150
CDT Code Maintenance
CDBP Code Advisory
Committee
• 21 voting members from all
sectors of the dental
community

Council on Dental Benefit
Programs has ADA
Bylaws responsibility for
maintenance
5 ADA, 5 Payer, 9 Dental
Specialties, 1 AGD, 1 ADEA
• Reviews change requests
& determines which to
accept or decline
© 2012 American Dental Association. All Rights Reserved
151
CDT Code Maintenance
• Process open to any interested party
– Requests from dentists as well as ADA, payers,
etc.
– Information about the process on-line
• http://www.ada.org/3827.aspx
• Questions?
– Council on Dental Benefit Programs (CDBP)
• [email protected]
• ADA member toll-free number or 312-440-2500
© 2012 American Dental Association, All Rights Reserved
152
?????
Your Questions
?????
before some closing comments
© 2012 American Dental Association, All Rights Reserved
153
CDT 2013
Includes:
>
>
>
The CDT Code
Illustrations of all
additions, revisions,
and deletions
Alpha Index
To order your copy, call 800-947-4746 or visit our
on-line product catalogue at www.adacatalog.org
© 2012 American Dental Association, All Rights Reserved
154
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”
© 2012 American Dental Association, All Rights Reserved
155
Dental Coding Made Simple
Includes:
>
>
>
Coding exercises and
Q&A
Comprehensive dental
claim form completion
instructions
Tooth and oral cavity
area code schemas
To order your copy, call 800-947-4746 or visit our
on-line product catalogue at www.adacatalog.org
© 2012 American Dental Association, All Rights Reserved
156
ADA Seal of Acceptance
Surveys show
patients trust you
– and use what
you recommend
© 2012 American Dental Association, All Rights Reserved
157
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 http://www.ada.org/seal
– Consumers: MouthHealthy.org at
http://www.mouthhealthy.org/en/ada-seal-products/
© 2012 American Dental Association, All Rights Reserved
158
ADA membership
To join - call 1-800-232-1382
Learn about member benefits at
www.ada.org
Member Service Center
312-440-2500
©©2012
2012 American Dental Association. All Rights Reserved
159

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