Dental Procedure CodesDental Procedure Codes

The Good, The Bad, and The UglyThe Good, The Bad, and The Ugly

CommunicationCommunication ““The language of reimbursement?”The language of reimbursement?”

DentalDental

ProcedureProcedure

Codes!Codes!

Fee-for-serviceFee-for-service

Third Party PayersThird Party Payers

Government ProgramsGovernment Programs

Why a CDT Code?Why a CDT Code?

Purpose –Purpose – Provide uniformity, consistency and specificity Provide uniformity, consistency and specificity

in accurately reporting (i.e., documenting) in accurately reporting (i.e., documenting) dental treatmentdental treatment

Use –Use – Populate patient health record – electronic Populate patient health record – electronic

and paper and paper Provide for the efficient processing of dental Provide for the efficient processing of dental

claimsclaims

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History of Dental CodesHistory of Dental Codes

American Academy of Periodontology American Academy of Periodontology introduced categories of services in 1967.introduced categories of services in 1967.

1969, Current Dental Terminology was 1969, Current Dental Terminology was introduced, and published for the first introduced, and published for the first

time in JADA.time in JADA.

The codes continued to be published in JADA The codes continued to be published in JADA from 1972 through 1987.from 1972 through 1987.

The first condensed version of a Current Dental The first condensed version of a Current Dental Terminology (CDT) manual was in 1979, also Terminology (CDT) manual was in 1979, also found in JADA.found in JADA.

In 1986, The ADA Council on Dental Benefit In 1986, The ADA Council on Dental Benefit Programs published the current version, in an Programs published the current version, in an educational format educational format

Dental Procedure Codes were designated under Dental Procedure Codes were designated under the Health Insurance Portability Act (HIPPA) as the Health Insurance Portability Act (HIPPA) as the national terminology for reporting dental the national terminology for reporting dental services recognized by third party payers services recognized by third party payers nationwide in 1996.nationwide in 1996.

They are the most commonly used codes for They are the most commonly used codes for reporting dental procedures (other accepted reporting dental procedures (other accepted coding sets include ICD-9, and HCPCS)coding sets include ICD-9, and HCPCS)

What is a code?What is a code?

A system of symbols (e.g., letters or A system of symbols (e.g., letters or numbers) that represent assigned meaningsnumbers) that represent assigned meaningsInformation that can be processed by a Information that can be processed by a computer without human interventioncomputer without human intervention D0150 D0150 is the dental procedure code that means is the dental procedure code that means

comprehensive oral examinationcomprehensive oral examination 1223G0001X1223G0001X is the provider specialty code for a is the provider specialty code for a

dentist in general practicedentist in general practice 01/01/2012 01/01/2012 is the code that means the first day is the code that means the first day

in the month of January in the year 2012in the month of January in the year 2012

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Components of a CDT Code Components of a CDT Code entryentry

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Procedure CodeFive character alphanumeric beginning with “D”

Nomenclature (name)Written title of the procedure

Descriptor (description)Narrative providing further definition and intended use of the procedure; most but not all codes have a descriptor

D0210 intraoral - complete series of radiographic images

A radiographic survey of the whole mouth, usually consisting of 14-22 periapical and posterior bitewing images…

Categories of ServiceCategories of Service

I.I. DiagnosticDiagnostic D0100-D0100-D0999D0999 VII.VII. Maxillofacial Maxillofacial

ProstheticsProsthetics D5900-D5999D5900-D5999

II.II. PreventivePreventive D1000-D1000-D1999D1999 VIII.VIII. Implant ServicesImplant Services D6000-D6199D6000-D6199

III.III. RestorativeRestorative D2000-D2000-D2999D2999 IX.IX. Prosthodontics - Prosthodontics -

fixedfixed D6200-D6999D6200-D6999

IV.IV. EndodonticsEndodontics D3000-D3000-D3999D3999 X.X.

Oral and Oral and Maxillofacial Maxillofacial SurgerySurgery

D7000-D7999D7000-D7999

V.V. PeriodonticsPeriodontics D4000-D4000-D4999D4999 XI.XI. OrthodonticsOrthodontics D8000-D8999D8000-D8999

VI.VI. Prosthodontics Prosthodontics – removable– removable

D5000-D5000-D5899D5899 XII.XII.

Adjunctive Adjunctive General General ServicesServices

D9000-D9999D9000-D9999

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The code manual’s technical content is the The code manual’s technical content is the responsibility of the Council on Dental responsibility of the Council on Dental Benefits of the ADA.Benefits of the ADA.

This includes the glossary, format, and This includes the glossary, format, and content of the manual.content of the manual.

The Code SetThe Code Set

The actual code set found in the manual, is The actual code set found in the manual, is changed through a process that includes changed through a process that includes not only the Council on Dental Benefit not only the Council on Dental Benefit Programs, but also third party payers and Programs, but also third party payers and specialty organizations.specialty organizations.

How are dental procedure codes How are dental procedure codes changed?changed?

In 2000, a code revision committee was In 2000, a code revision committee was established to update the code bi-established to update the code bi-annually.annually.

It consisted of an equal number of It consisted of an equal number of members from the Council on Dental members from the Council on Dental Benefit Programs and Third Party Payers, Benefit Programs and Third Party Payers, such as Delta, MetLife and NADP. such as Delta, MetLife and NADP.

Beginning in 2013, the process was Beginning in 2013, the process was changed to provide more input by changed to provide more input by

establishing the Code Maintenance establishing the Code Maintenance CommitteeCommittee

There are 22 voting members of the CMC There are 22 voting members of the CMC including ADA members with code including ADA members with code experience, a representative from each experience, a representative from each specialty organization and the Academy of specialty organization and the Academy of General Dentistry, and Third Party Payers.General Dentistry, and Third Party Payers.

Each member has one vote on the Each member has one vote on the committeecommittee

Also beginning in 2013, changes in the Also beginning in 2013, changes in the code set will occur annually, rather than code set will occur annually, rather than biannually as in the past.biannually as in the past.

The 2014 edition of the CDT Manual The 2014 edition of the CDT Manual includes 641 dental procedure codes.includes 641 dental procedure codes.

20 orthodontic codes20 orthodontic codes 34 periodontal codes34 periodontal codes 132 oral surgery codes132 oral surgery codes

Changes in the CodeChanges in the Code

Any person, group, or organization can Any person, group, or organization can request a change in the dental procedure request a change in the dental procedure codes.codes.

Changes are classified as new codes, Changes are classified as new codes, deleted codes, or code revisions.deleted codes, or code revisions.

Control Identifier (CID): aaa-nn Page 1 of 1 (ADA Use Only)

CDT Code – Code Action

1. Requestor Information Date Submitted:

Name:

Address (Line 1):

Address (Line 2):

City: State: Zip Code

Telephone: Email:

2. Does this request represent the official position of: a) a dental organization or a recognized dental specialty; b) a third-party payer or administrator; or c) the manufacturer/supplier of the product?

Yes > If Yes, Name:

No >

3. Does the requestor or entity identified in item #1 or #2 receive any financial benefit?

Yes > If Yes, describe:

No >

4. Action Add Revise Delete Affected Code (Revisions & Deletions) D

5. Full text of requested action (Additions & Revisions)

Nomenclature

Descriptor

6. Rationale for this request (e.g., reasons why existing procedure code is inadequate or no longer appropriate; description of technology inherent to procedure; dental schools where taught).

7. For Additions – a) current CDT Code used to report the proposed procedure; b) description of the procedure or clinical condition; and c) scenario describing the patient, materials, technique, etc.

8. Supporting documentation or literature: a) if protected by copyright, written authorization to reprint and distribute must be provided; and b) all material must be submitted in electronic format.

Material submitted?

Yes > Protected by copyright?

Yes > Permission to reprint?

Yes >

No > No > No >

9. Additional Comment/Explanation:

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Guidelines for changes:Guidelines for changes:

Requests should be based on the need to accurately Requests should be based on the need to accurately document procedures performed.document procedures performed.They should be concise, clear, and not ambiguous.They should be concise, clear, and not ambiguous.Time limitations should not be included.Time limitations should not be included.Unbundling or fragmenting an existing procedure into it’s Unbundling or fragmenting an existing procedure into it’s component parts is not permitted.component parts is not permitted.It should refer to a procedure and not a specific trade It should refer to a procedure and not a specific trade name, technique, or instrumentationname, technique, or instrumentationRequests pertaining to newly developed procedures are Requests pertaining to newly developed procedures are encouraged to include documentation of clinical efficacy.encouraged to include documentation of clinical efficacy.

In Actuality:In Actuality:

When being considered, there are a few things When being considered, there are a few things that strengthen the request:that strengthen the request:

Is the procedure taught in dental schools?Is the procedure taught in dental schools? Is there literature to support the request?Is there literature to support the request?

Are there multiple requests?Are there multiple requests?

Is it requested and/or supported by CDBP Is it requested and/or supported by CDBP and specialty organizations?and specialty organizations?

Timeline for the Code Revision Timeline for the Code Revision ProcessProcess

Closing date for submitting a request is Closing date for submitting a request is November 1.November 1.The Code Maintenance Committee meets The Code Maintenance Committee meets in February-March the following year.in February-March the following year.Decisions are sent out to requestors in Decisions are sent out to requestors in early April and posted on ADA.org for early April and posted on ADA.org for public informationpublic informationPreparation of CDT Manual for following Preparation of CDT Manual for following year is complete by early May.year is complete by early May.

Changes effective – 01/01/2013Changes effective – 01/01/2013

161 code change requests161 code change requests submitted for considerationsubmitted for consideration

35 Additions in 8 categories 35 Additions in 8 categories 37 Revisions in 9 categories 37 Revisions in 9 categories 12 Deletions12 Deletions in 4 categoriesin 4 categories

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New Periodontal Codes 2013New Periodontal Codes 2013

Previously, the code for a free gingival graft:Previously, the code for a free gingival graft: 4271 Free soft tissue graft procedure, 4271 Free soft tissue graft procedure, (including donor site surgery) (including donor site surgery)

Beginning in 2013, the codes are:Beginning in 2013, the codes are: 4277 Free soft tissue graft procedure (including4277 Free soft tissue graft procedure (including donor site surgery), first tooth or edentulous donor site surgery), first tooth or edentulous tooth position in grafttooth position in graft 4278 Free soft tissue graft procedure (including 4278 Free soft tissue graft procedure (including donor site surgery), each additional contiguous donor site surgery), each additional contiguous tooth or edentulous tooth position in sametooth or edentulous tooth position in same graft sitegraft site

What’s on the horizon?What’s on the horizon?

Codes for procedures using lasers (???)Codes for procedures using lasers (???)

Expanding current codes to allow use of Expanding current codes to allow use of new materials (e.g. GINTUIT, etc)new materials (e.g. GINTUIT, etc)

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AAP InvolvementAAP Involvement

Division of Public, Practice, and ScientificDivision of Public, Practice, and Scientific

AffairsAffairs

Patient Benefits and Advocacy Patient Benefits and Advocacy

CommitteeCommittee

Recommend adoption of appropriate codes to benefit diagnosis and treatment

Correspond and meet with dental directors, consultants, benefit purchasers, dental plan designers and others to advocate benefits for patients’ periodontal treatment

Assist members in resolving reimbursement problems

Code Maintenance CommitteeCode Maintenance Committee

ADA Standards Committee on DentalADA Standards Committee on Dental InformaticsInformatics

SNODENTSNODENT

ICD-9 and ICD 10ICD-9 and ICD 10

Dental Quality AllianceDental Quality Alliance

Code Maintenance CommitteeCode Maintenance Committee

Represents AAP interests in coding: Insurance Represents AAP interests in coding: Insurance Consultant represents AAP at tableConsultant represents AAP at table

Decisions are made through a process that involves the Decisions are made through a process that involves the AAP Insurance Consultant, Patient Benefits and AAP Insurance Consultant, Patient Benefits and Advocacy Committee, and the Board of Trustees.Advocacy Committee, and the Board of Trustees.

Consults with third party carriers and has input from Consults with third party carriers and has input from membership for code revisionsmembership for code revisions

ADA Standards Committee on ADA Standards Committee on Dental InformaticsDental Informatics

Representation on committee establishing Representation on committee establishing parameters and standards for electronic parameters and standards for electronic communicationcommunication

Determines requirements for standardization Determines requirements for standardization of claims submission for electronic of claims submission for electronic submissionssubmissions

SNODENTSNODENT

Has input for periodontal diagnostic codes Has input for periodontal diagnostic codes developed by the ADAdeveloped by the ADA

Monitors updates and changes Monitors updates and changes

ICD-9 and ICD-10ICD-9 and ICD-10HCPCSHCPCS

Monitors updates and changes for medical Monitors updates and changes for medical diagnostic (ICD-9) and procedure codes diagnostic (ICD-9) and procedure codes (HCPCS) applicable to periodontics.(HCPCS) applicable to periodontics.

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ADA claim form – Diagnosis ADA claim form – Diagnosis CodesCodes

ICD-9-CM Diagnosis Code (at least one)

Diagnosis Code Pointer

Dental Quality AllianceDental Quality Alliance

Voting member of alliance to develop quality Voting member of alliance to develop quality measurements for the dental professionmeasurements for the dental profession

Educational OpportunitiesEducational Opportunities

Annual Meeting Insurance Workshops:Annual Meeting Insurance Workshops:

Dental and medical coding Dental and medical coding

for reimbursementfor reimbursement

State and Regional Insurance State and Regional Insurance

WorkshopsWorkshops

AAP Complaint Resolution ProcessAAP Complaint Resolution Process

Designed to provide assistance for codingDesigned to provide assistance for coding

and insurance issues for membersand insurance issues for members

Member fills out complaint form including patient signature to release information

Release and all reimbursement documentation and records are sent to AAP central office

AAP Insurance Consultant contacts third party payer to facilitate discussion regarding claim and benefits

Resolution of complaint may include additional reimbursement, explanation of plan benefits, etc.

The statisticsThe statistics

AAP received 1352 and 1287 calls in 2011 and AAP received 1352 and 1287 calls in 2011 and 2012 respectively that involved the complaint 2012 respectively that involved the complaint resolution process.resolution process.

In the last two years, it has resulted in over In the last two years, it has resulted in over $50,000 in additional benefits for members and $50,000 in additional benefits for members and patientspatients

In 2012, over 250 calls were received regarding In 2012, over 250 calls were received regarding medical benefitsmedical benefits

Additional member services asAdditional member services as result of the complaint resolution result of the complaint resolution

process:process:

Facilitation of EOB language complaintsFacilitation of EOB language complaints

Face-to-face meetings with third party Face-to-face meetings with third party dental directors to discuss issues including dental directors to discuss issues including benefits and plan detailsbenefits and plan details

Resolution of administrative issues with Resolution of administrative issues with third party payersthird party payers

The complaint resolution process not only The complaint resolution process not only provides a unique service for members, provides a unique service for members, but also encourages communication but also encourages communication between the specialty and third party between the specialty and third party payers. Many times the Academy is payers. Many times the Academy is consulted regarding policies, interpretationconsulted regarding policies, interpretation

guidelines, and other administrative guidelines, and other administrative decisions. decisions.

So how does this fit into residency So how does this fit into residency programs?programs?

Beginning a practice or joining a Beginning a practice or joining a group practice can be group practice can be

overwhelmingoverwhelming::

Fee-for-service vs contractual plansFee-for-service vs contractual plans

Participant vs Non-participantParticipant vs Non-participant

Contract analysisContract analysis

Residents need practice management resources Residents need practice management resources when they begin practice:when they begin practice:

-Recognizing the importance of dental procedure coding in -Recognizing the importance of dental procedure coding in clinical practiceclinical practice

-How to submit for reimbursement, saving time and money-How to submit for reimbursement, saving time and money

-Receiving optimal reimbursement-Receiving optimal reimbursement

-Troubleshooting insurance problems-Troubleshooting insurance problems

-Electronic filing-Electronic filing

Best Practices for the PeriodontistBest Practices for the Periodontist

EthicalEthical

Guidelines for careGuidelines for care

Legal responsibilitiesLegal responsibilities

What can the AAP do to help?What can the AAP do to help?

What materials can the AAP provide to What materials can the AAP provide to programs?programs?

What is the best method of delivering the What is the best method of delivering the information?information?

How and when can it be best integrated How and when can it be best integrated into programs?into programs?

Some ideasSome ideas

Annual meeting workshop for residents on coding and Annual meeting workshop for residents on coding and third party issues? third party issues?

Webinars over the course of the year to introduce Webinars over the course of the year to introduce residents to these practice management issues?residents to these practice management issues?

Support for faculty to integrate third party issues into the Support for faculty to integrate third party issues into the curriculum?curriculum?

We are a wealth of information!