Recent changes in coding are imporant for you to know — for your office and patients
By Olya Zahrebelny, DDS
Thanks to the recent changes associated with HIPAA compliance and the introduction in January of new dental CDT-4 codes, there is a lot of confusion as to the correct code selection — not only from a legal standpoint, but also in consideration of minimizing patient out-of-pocket expenses. This two-part article (the second part will appear in the March issue of Dental Equipment & Materials) will clarify the codes that should be used, together with their updated or revised descriptions, and the current restrictions that are written into the majority of dental benefit plans on the market today. By updating your knowledge, business staff will then be able to better advise patients and schedule their appointments to maximize their plan's reimbursement dollars.
CDT-3 or CDT-4? Which codes do I use and does it matter?
Unless your office filed an extension for HIPAA compliance, you are mandated by law to code dental claims using CDT-4 codes. This law went into effect on Jan. 1. Those offices that filed an extension may continue using CDT-3 codes until Oct. 16, 2003, after which time they also will be bound to using the CDT-4 codes. Dental insurance companies also are required by law to conform to the HIPAA filing requirements, including the correct use of codes. There will be no exceptions.
The advantages of HIPAA
The introduction of HIPAA conformity in the billing process will result in many advantages to the dental offices where frustration with claims submission and reimbursement has run high. HIPAA rules and regulations will allow for the following, from all insurers:
- responses to benefit requests available immediately over the Internet, including patient eligibility, plan maximums, deductible, and co-payment;
- immediate responses to pre-determinations;
- ability to check the status of a submitted claim;
- conformity in dental coding;
- identical claim submission format;
- payments and adjustments posted directly to your practice-management software; and,
- information will be available to be downloaded and printed for immediate responses to patient questions.
This will apply to offices submitting claims electronically only.
Examinations and evaluations —New codes and revised descriptions
This now includes periodontal screening. This is not a comprehensive periodontal evaluation.
This code should be selected for use when evaluating a patient for:
- a specific problem such as an oral lesion or wisdom tooth eruption;
- dental emergency;
- traumatic injury (although, ideally, this should be billed to the medical carrier); or,
- acute infection.
In order to bill the COE, the following procedures must be performed as part of the comprehensive examination:
- Subjective evaluation — includes the patient's medical history and his or her chief complaint (in his or her own words);
- Objective evaluation — Extraoral, to include palpation of the lymph nodes, TMJ, evaluation, facial symmetry, and lesions;
- Objective evaluation — Intraoral, including soft- and hard-tissue pathology, charting of the teeth (existing restorations, radiographic observations and pathology, any fractures, previous treatment, and the like);
- Oral cancer screening;
- Periodontal charting
The common restrictions on this code are that it is limited to once per provider per lifetime — although the appropriate use of the code is once initially — and then again if the patient has been away from the practice for a period of more than two years. It can be used by both general practitioners and specialists, although a more specific code has been introduced for use by periodontal specialists, that being D0180 Comprehensive Periodontal Evaluation.
D0160 Detailed and Extensive Evaluation. New code
This code is specifically chosen for situations where the patient's presenting condition is unusually complicated and the problems many and extensive in their scope. The patient's situation may require the involvement of several specialists and consultations with medical professionals as well. This code is preceded by code D0150, with no time interval restriction.
To be used for follow-up of patients seen initially for a limited oral evaluation. The typical plan restriction is a minimum of seven days following the date of service for D0140. This code is selected for the following situations:
- in traumatic injury situations, where no treatment was needed or rendered, but follow-up is indicated;
- for the monitoring of continuous pain;
- oral pathology requiring follow-up.
To be used for either a new or established patient in the practice. It is indicated specifically for patients who show signs of periodontal disease and/or those with certain medical indications for being prone to periodontal disease, such as diabetics and patients taking beta-blockers (Procardia, epileptics on Dilantin, etc.).
A comprehensive periodontal evaluation consists of probing and charting, an evaluation of the medical and dental histories, and an overall health assessment. It also may include charting of the teeth, including missing and unerupted teeth, as well as caries, occlusal anomalies or discrepancies, and the like. This code cannot be used following any other evaluation by the same practitioner. Therefore, it would be inappropriate to use D0150 followed by D0180 on a subsequent date of service, or even the same day.
Radiographs and photos/images —New codes and revised descriptions
D0277 Vertical Bitewings (7-8). New Code
With the obvious diagnostic advantage that vertical bitewings provide in evaluating periodontal pathology, it comes as no surprise that a large percentage of offices are now using them in place of the traditional series of four horizontal bitewings as part of the full mouth radiographic series, or during the periodic oral evaluation visit. Unfortunately, dental plan restrictions on this procedure are currently treating the code as being used in place of an FMX and denying benefits, imposing the FMX plan limitations on them. This should change with the CDT-4, since the ADA has specifically stated that D0277 "does not constitute a full-mouth series."
It remains to be seen at this time whether the dental plans will change their reimbursement for this code. Other plans are converting the code internally to D0274 and paying with that assigned reimbursement. Since code conversions will no longer be allowed with the new HIPAA regulations, it remains to be seen whether benefit allowance will change to reflect the additional number of X-rays.
D0350 Extraoral and Intraoral Photos and Images. New Code
This code is self-explanatory and includes photos and images taken with an intraoral camera, as well as those taken with a digital or traditional camera. There is currently no reimbursement available through any dental plan for this procedure code.
Prophylaxis and periodontal treatment —New codes and revised descriptions
D04355 Gross Debridement replaced code 004345. New code
When it is impossible to perform a periodontal charting as part of the COE, then it is necessary to perform a gross debridement in order to chart the patient and evaluate the type of treatment required. The appropriate use of this code is for patients presenting with abundant calculus deposits, bleeding, and inflammation. It can be performed as a precursor to other periodontal procedures, including the series D4200 and D4300 codes.
Plan allowances, when the procedure is covered, are typically once per provider per lifetime. Only about 50 percent of contracts cover this code, so be certain to inform patients of the limitations. Use of this code does not exclude the patient from benefits for the series D4200 and D4300 procedures.
D4910 Periodontal Maintenance. Revised description
First of all, the periodic evaluation is no longer part of the code description. The description was also revised to include "the periodontal probing and inspection of tissue necessary to determine changes in the periodontium," defined as being a periodontal evaluation. This code clearly indicates that it should be used "following active periodontal therapy," which means scaling and root planing (D4341) and/or periodontal surgery (D4200 series codes). The code description also states that, "a typical interval of three months between appointments results in an effective treatment schedule." This does not mean that it will be a covered plan benefit every three months. Typical coverage includes two "cleanings" a year, either D1110 Adult Prophylaxis or D4910 Periodontal Maintenance. The two codes cannot be alternated, regardless of whether they are being performed at the periodontist's or the general dentist's office. There must be a consistency in the use of the codes. It also is very important to note that the D4910 code is specifically worded as, "Periodontal maintenance treatment following periodontal therapy is not synonymous with a prophylaxis."
Note: When submitting periodontal claims for predetermination or payment, a periodontal diagnosis is now going to be required. All periodontal claims also require periodontal charting (six points per tooth), periapical and bitewing X-rays of the areas to be treated (regardless of whether the problem is visible radiographically or not), and photographic documentation if the problem is not obvious or supported by the documentation presented and can only be seen on a photograph, i.e. the need for a CT graft, where pocketing and bone levels are normal, but recession is present.
D1110 Adult Prophylaxis. Revised description
There have been two changes made to the description of this code. The first is the insertion of the word "or" in the first sentence. It now reads, "A dental prophylaxis performed on transitional or permanent dentition that includes scaling and/or polishing procedures to remove coronal plaque, calculus, and stains." This small but significant change allows for the use of this code not only in the traditional sense as part of the periodic visit, but also as the last visit of a series of scaling and root planing procedures, part of a soft-tissue management (STM) series.
The second change is the deletion of the last two sentences from the CDT-3 description, which now reads, "Some patients may require more than one appointment or one extended appointment to complete a prophylaxis. Document need for additional time or appointments." The ADA's Code Revision Committee felt that there was too much confusion with this descriptor.
Keep in mind also that use of the prophylaxis code for routine "cleaning" appointments is limited to patients whose pocket depths are routinely 4mm or less. With the revised description changes, it also is now appropriate for use in patients undergoing a polishing as the final step of their STM series.
D4341 Scaling and Root Planing
Plan restrictions for this code include a limitation of once every two years. It also is important to note that osseous surgery, if necessary, should be performed after re-evaluation at the six-week stage. Benefit payment will be reduced by the amount paid for the S&RP if it is performed sooner.
D4340 Scaling and Root Planing (not an ADA code)
This is an internal code used by the Delta plans for four quadrants of D4341 billed with the same date of service. It is not a recognized ADA code and should not be used for billing S&RP procedures. Benefits are typically reduced for four quadrants of scaling and root planing performed on the same day.
Nightguards and TMD orthotics
There is a considerable amount of abuse associated with the use of these codes, more commonly with the TMD orthotics. To clarify their appropriate uses, nightguards (D9940) are used to treat bruxism and its associated symptoms. Orthotics (D7880) are used in patients indicating TMJ problems and symptoms and/or radiographic evidence of a progressive disease process and associated pain. Both appliances are typically covered under the patient's medical policy and it is recommended that billing be to the medical plan using the appropriate ICD-9 and CPT codes, submitted on the HCFA-1500 medical claim form. It is important to emphasize that TMD claims require the necessary documentation in the form of a TMD Evaluation Form, radiographs, and chart notes in the SOAP (S=subjective, O=objective, A=assessment, P=plan) format.
Dr. Olya Zahrebelny is in a private group practice in downtown Chicago, has taught at three dental schools, and practiced in both hospital and private-practice settings. She also has worked as a consultant to both commercial and government insurance plans. She is an editor, columnist, and author of numerous articles and publications related to practice management and insurance billing/reimbursement. Medical billing manuals and further information can be obtained by calling (847) 675-3006 or by e-mail at [email protected].