Montana Dental Association May 2, 2013 2012 American

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 ADAs 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 Codes 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 wont 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 5 2012 American Dental Association, All Rights Reserved 6 2012 American Dental Association, All Rights Reserved

7 2012 American Dental Association, All Rights Reserved 8 What is the CDT Code Shorthand for the ADAs 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 10 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 11 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 D0100D0999 D1000D1999 VII. Maxillofacial Prosthetics

VIII. Implant Services D5900D5999 D6000D6199 I. Diagnostic II. Preventive

III. Restorative D2000D2999 IX. IV. Endodontics D3000D3999 X.

V. Periodontics D4000D4999 XI. Orthodontics D8000D8999 VI. Prosthodontics removable

D5000D5899 XII. Adjunctive General Services D9000D9999 Prosthodontics fixed Oral and Maxillofacial Surgery D6200D6999

D7000D7999 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 14 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 dentists 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

image bitewing single radiographic 2012 American Dental Association, All Rights Reserved 19 Pre-diagnostic Services D0190 screening of a patient A screening, including state or federally mandated screenings, to determine an individuals 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 20 Preventive One for two One addition as replacement for two deletions D1208 D1203 D1204 topical application of fluoride

topical application of fluoride child 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

21 Preventive One revision Before change As revised D1206 topical fluoride varnish; therapeutic application for moderate to high caries risk patients D1206 topical application of fluoride varnish

Application of topical fluoride varnish, delivered in a single visit and involving the entire oral cavity. Not to be used for desensitization. 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 23 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 crackedtooth 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 24 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

25 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 26 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 29 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 30 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 31 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 32 Implant Codes Single Crowns Implant D6010 Abutment prefabricated D6056 custom D6057 Crown D6058-64 0r 6094 titanium 2012 American Dental Association, All Rights Reserved

33 Implant Codes If no abutment Implant D6010 Crown implant supported D6065-67 2012 American Dental Association, All Rights Reserved 34 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 35 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 D6254interim pontic D6795interim retainer crown

Prompted by duplication of codes in restorative category D6970post and core in addition to fixed partial denture retainer, indirectly fabricated D6972prefabricated post and core in addition to fixed partial denture retainer D6973core buildup for retainer; including any pins D6976each additional indirectly fabricated post same tooth D6977each additional prefabricated post same tooth 2012 American Dental Association, All Rights Reserved 39 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 procedures

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 ADAs 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 patients dental benefit plan BUT Your treatment plan should be based on the patients 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 unspecifiedprocedure, 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 Codes 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 patients 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 practitioners 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 codes 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 Codes perspective > But payer may make single reimbursement based on benefit plan design > Dentists 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 dentists 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 patients 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 payers 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 patients 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 patients 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 patients condition? 0? 0 0 D0 cal n i Top licatio Ap p

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 its 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 D0140 limited oral evaluation problem focused D2970 temporary crown (fractured tooth)

D9440 office visit - after regularly scheduled hours Why ? Patient presented with a specific problem This procedure code applies when providing immediate protection for the fractured tooth Care was provided when the office was closed 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 patients mouth) D2740 crown These codes apply no matter porcelain/ceramic where the post & core, or substrate crown, are fabricated in the dentists 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 patients 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 Patients 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 Code Selected / # Why ? 14 D2392 resin-based composite two surface, posterior 19 19 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 Dentists 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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