By Carol Tekavec, CDA, RDH
The ADA Code Revision Committee finalized codes for the newly revised Current Dental Terminology late last summer. The new CDT-2005 codes, which went into effect on Jan. 1, 2005, will be required until the next revision process comes to an end, with new codes revealed for January 2007. According to HIPAA regulations, all providers and payers must use the current version of the ADA codes. The Code Revision Committee (CRC) accepts change requests in an on-going fashion. Those interested in submitting changes may go to www.ada.org/goto/dentalcode or may call the Council on Dental Benefit Programs at (312) 440-2753.
The CDT-2005 contains 39 new codes, 47 revisions, and three deletions. This article will highlight notable changes.
D0150-Comprehensive Oral Evaluation-New or Established Patient -This code has been revised to indicate it is valid for new patient evaluations as well as exams for patients of record who have not had a comprehensive evaluation for three or more years. While many carriers have long considered D0150 to include these parameters, this CDT-2005 revision indicates agreement. Most carriers will pay a benefit toward D0180-Comprehensive Periodontal Evaluation, New or Established Patient, and D0150 under the same parameters. In other words, most carriers consider D0180 and D0150 to refer to comprehensive evaluations, despite the differences in the exact wording of their descriptions. Many carriers cover a comprehensive evaluation once every three to five years.
D1110 Prophylaxis-Adult - This code seems to be revised for every CDT publication. The CDT-2005 definition is, “Removal of plaque, calculus, and stains from the tooth structures in the permanent and transitional dentition. It is intended to control local irritational factors.” The previous definition in CDT-4 indicated “removal of coronal plaque, calculus, and stains” and no mention of “local irritants.” The new wording of “tooth structures” and “to control irritational factors” clarifies how the CRC defines an adult prophylaxis. It is believed that the ADA considers this to be the appropriate code to use for any scaling and polishing procedure for an adult in a healthy oral state or in any other condition other than those presenting with deposits that hinder an evaluation. It may apply to patients presenting with supra and subgingival deposits, as well as gingival inflammation. Most carriers will cover a D1110 twice annually and consider it to apply to patients age 14 and above.
The “topical fluoride” definition has also been revised again for the CDT-2005. It was previously described as not including a “rinse or swish,” (with that definition later expanded to include a professional-strength rinse or swish). Now the description indicates that a topical fluoride procedure must include “a prescription-strength fluoride product designed solely for use in the dental office, delivered to the dentition under the direct supervision of a dental professional.” Benefits for fluoride treatments are frequently limited to twice per year or once in a six-month period for children through age 13. A few carriers will provide a benefit for adults with root sensitivity or documented cervical decay.
There is a new code for a Titanium Crown-D2794. This code is believed to be appropriate for a full titanium metal crown, or a porcelain, or any other surface material fused to titanium crown. Code D2910-Recement Inlay, Onlay, or Partial Coverage Restoration changed nomenclature with the addition of the words, “onlay and partial coverage restoration.” This code now is believed to cover the recementation of veneers, which previously had no separate code. Many carriers will cover such recementations if the restoration has been in place for at least six months.
In the area of periodontics, the CRC made changes to several codes to make their descriptions consistent. The codes for quadrants now are consistent for number of teeth or “bounded teeth spaces.” (“Bounded teeth spaces” might be illustrated with periodontal treatment performed on #2, #3, and #5 where #4 is missing. The edentulous area where #4 is missing is a “bounded tooth space.”)
D4910-Periodontal Maintenance - This code description now includes implant replacements. It still does not include the dentist’s exam or evaluation, although the maintenance intervals are “determined by the clinical evaluation of the dentist.” Therefore, it is believed that an evaluation may still be appropriately coded separately. Some carriers are beginning to pay a benefit for both an evaluation and perio maintenance performed on the same date, but will reduce the amount typically paid for each procedure. Any evaluation code may be used along with the D4910, but most carriers will only provide a benefit for a D0120-Periodic Oral Evaluation. Many carriers will cover two “cleanings” (of any type, including D4910) and two D0120 procedures annually.
D4381-Localized Delivery of Antimicrobial Agents via a Controlled Release Vehicle into Diseased Crevicular Tissue, per Tooth, by Report - This code description and nomenclature have changed. Formerly, the wording mentioned “chemotherapeutic” agents and did not specify that the medications used must be FDA-approved. Carriers that provide a benefit for this code frequently require previous perio surgery or root planing/scaling. A few carriers are providing a benefit for D4381 at the same time as root planing/scaling, with stipulations such as a minimum Case Type III (moderate periodontitis), at least 5 mm pockets on the teeth to be treated, bleeding, and a maximum of two teeth per quadrant considered. Further requirements might be that no future periodontal surgery would be covered in the D4381 areas for one year to 18 months.
Note: Many patients do not understand the limitations of dental insurance for periodontal treatment, nor do they comprehend the differences between a regular “cleaning,” root planing, and periodontal maintenance. To view the text of an educational patient brochure, go to www.steppingstonestosuccess.com and click on “products.”
D6020-Abutment Placement or Substitution: Endosteal Implant has been deleted. Codes D6056 Prefabricated Abutment and D6057 Custom Abutment have been revised to “include placement” and may be used instead.
D7288 Brush Biopsy-Transepithelial Sample Collection is a new code that describes the OralCDx brush biopsy. The ADA is spotlighting the test as an important service dentists can provide. Some dental carriers will provide a benefit for this procedure, with a patient’s medical plan covering the lab fee (it is said that the medical claim may be filed directly by the OralCDx laboratory.) It is believed that a benefit will also be likely for a subsequent D7286-Biopsy of Oral Tissue-Soft (incisional biopsy) when D7288 samples show “atypical” cells.
Many other codes have been added or revised. Because patients seldom understand their insurance and what it will cover, it is beneficial for a dental practice to be up-to-date on current coding, typical insurance processing guidelines, and possible payment. Most patients with insurance want their insurance to pay the maximum, and most offices realize that insurance helps patients pay for the treatment they need.
Carol Tekavec, CDA, RDH, is the author of the Dental Insurance Coding Handbook-Updated for CDT-2005, as well as brochures on the limited nature of insurance, “My Insurance Covers This...Right?” and “What is the Difference Between a ‘Regular’ Cleaning, a Root Planing, and Periodontal Maintenance?” She is the insurance columnist for Dental Economics magazine and a lecturer with the ADA Seminar Series on Record Keeping and Insurance. Contact her by phone at (800) 548-2164 or visit www.steppingstonestosuccess.com.