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Recent changes in coding are important for you to know — for your office and patients

By Olya Zahrebelny, DDS

The second article in this two-part series will cover new and revised codes for the following categories of service that appear in the CDT-4:

• Emergency visits
• Endodontic treatment
• Restorative treatment
• Prosthodontics — fixed and removable

• Tooth-supported, individual teeth
• Tooth-supported, part of a bridge
• Implant-supported

• Surgery
• Desensitizing treatments

Emergency visits: the four most important codes

One of the greatest challenges to the billing staff is the selection of codes for services provided on an emergency basis. These procedures can be simplified if one considers that most of them are either related to deep caries or traumatic injury. The four most common codes include:

D9110 Palliative Treatment — this code is used to describe a pain-relieving procedure when there is no other more specific code that describes the service provided. Some typical procedures that this code can encompass are opening a tooth to drain, smoothing a fractured tooth, and denture adjustments.

D2940 Sedative Treatment — when the dentist has placed a temporary restoration after excavating caries — either in preparation for the definitive restoration if time does not allow this to be done at the time of the visit — or as a diagnostic tool to determine further treatment options, this is then the appropriate code. It can be used to code the placement of temporary restorations with materials such as IRM®, Cavit®, and glass ionomers.

D3220 Therapeutic Pulpotomy. Code Clarification

This code describes the removal of the coronal portion of the pulp, including the pulp chamber down to the opening of the canals. This is a definitive treatment with limitations being that the tooth be a primary tooth or a permanent tooth with open apices, where no further endodontic treatment will be performed. Therefore, this limits the procedure to children under the age of 14.

D3221 Gross Pulpal Debridement. New Code

When the pulp is removed in toto, meaning completely, pulp chamber and nerves in the canals, then this code is most appropriate. The patient is then referred for definitive endodontic therapy to a specialist.

If the general dentist performs this procedure as a first visit endodontic therapy, with the intention to continue treatment at the next appointment, then this code cannot be used. The correct code then becomes the appropriate endodontic code, depending on the number of canals involved.

Endodontic therapy: the introduction of seven new codes

D3331 Treatment of Root Canal Obstruction

In the process of canal instrumentation, pulpal stones, canal strictures, and impediments to apical access are occasionally encountered, necessitating non-surgical approaches. Typically, this makes the endodontic therapy more difficult and frequently requires referral to an endodontist. This code is used in addition to the endodontic code describing the tooth involved and the number of canals. Depending on the time spent, a fee proportionate to the additional time required is then assigned to this procedure.

D3332 Incomplete Endodontic Therapy

At times, it is impossible to complete therapy for several reasons — the pain is not diminishing, leading the dentist to suspect a vertical fracture undetected on radiographs, or the canals are partially or completed calcified, making instrumentation impossible and an accurate fill improbable. Rather than using the endodontic code to describe the procedure — D3310, D3320, D3330, etc. — this code then becomes the more appropriate one. Once again, a partial fee is then assigned to the procedure, based on the time spent. Typically the tooth may be treated with a fill as complete as possible, under the circumstances, or the tooth is extracted.

D3333 Internal Root Repair of Perforation

Should the general dentist perforate through the root when performing endodontic procedures, the patient then requires root repair of the perforation. For logical reasons, this procedure is not paid to the dentist that actually perforated the root, but is paid to the dentist that repaired the damage, typically the endodontist. Since the prognosis for the tooth is now diminished, many plans do not cover this procedure, anticipating extraction in the near future.

D2955 Post Removal

When an endodontically treated tooth requires retreatment, it may have previously been restored using a post and core buildup and crown. This code is used when the provider removing the post does not perform the subsequent endodontic retreatment. If the dentist that removes the post also retreats the tooth, then the post removal is included in the retreatment code, selected from one of the following: D3346 Retreatment of an anterior tooth; D3347 Retreatment of a bicuspid tooth; or D3348 Retreatment of a molar tooth

Restorative treatment

The most frequently encountered error in coding composites involves the use of code D2335 Composite Resin involving four or more surfaces or the incisal angle. Thus any time either the mesio-incisal or disto-incisal angle is involved, regardless of how many other surfaces are involved, this code is the most appropriate one to describe the composite resin procedure.

D2337 Resin-based Composite Crown. New Code

When a large portion of the tooth has been damaged or destroyed, and the tooth is not yet ready for a crown for reasons due to age of the patient or financial constraints, the tooth is restored using a crown form and resin-based composite. The restrictions on this code are typically for patients under the age of 18. When used for adults, the crown limitation applies.

D2388 Resin-bonded Composite. New Code

This code describes a composite resin placed on a posterior tooth, involving four or more surfaces.

Limitations on restorative procedures

1. Current plan limitations are 24 months for resins and amalgams, although some contracts limit replacement to once every five years.
2. Composites are covered when placed on anterior teeth. Approximately half of the dental plans cover composites on premolars, while molar placement is rarely covered, and is often alternated to an amalgam benefit.
3. Inlays are commonly converted to and paid as amalgams and onlays are converted to and paid as crowns.

Prosthodontics — Fixed and Removable

i. Tooth-supported prosthodontic treatment: crowns, posts, and cores on individual teeth (not part of a bridge)

D2542 Gold Onlay. New Code

This code applies to a two-surface onlay, covering one or both cusps.

D2780-D2783 Crowns. New Codes

When three out of four surfaces of a tooth are covered, in addition to the occlusal surface, one of these codes is selected, depending on the materials used.

D2799 Provisional Crown. New Code

A crown that is placed to provisionalize a tooth while other treatment is being provided, prior to final restoration placement, is often left in place for a period extending six months or more. It is also often laboratory-fabricated to ensure longevity, such as Biotemp®. These types of crowns may be paid under dental plan provisions, but then the permanent crown denied. It is best to inform the patient of this and to have the patient pay for this less-costly treatment out-of-pocket, with the permanent crown then covered under the plan.

D2970 Temporary Crown. Code Clarification

The difference between a temporary and provisional crown is the length of time that the crown is expected to be in the mouth prior to permanent crown fabrication. The temporary crown is made chairside of resin-type materials. It is commonly placed when determining further treatment options. A temporary crown may often not last for longer than six to eight weeks due to the materials used in its fabrication and the cements used for placement. Dental plans consider this temporary treatment and do not cover their fabrication.

D2960 Resin Veneer/chairside. New Code

When a composite resin is used to veneer a tooth due to fracture/caries, or to cover discolorations, this is the appropriate code. Keep in mind, however, that when billing using this code, the reason for veneering should be indicated in the "remarks" section of the claim form or, better still, a photograph should be attached to the claim itself.

D2961 Resin Veneer/lab-fabricated. New Code

A veneer can be made of either resin or porcelain-type materials. This code is self-explanatory and is a two-stage veneer procedure, with or without temporization.

D2962 Porcelain Veneer. New Code

Again, this is a two-stage procedure, involving a lab in the process.

D2953 Additional Cast Post. New Code

When a cast post and core requires that a second post be incorporated into the casting for added retention, the code D2952 is used, with the tooth number indicated, followed on the next line by code D2953, again with a tooth number indicating the second post in the casting and an additional fee (typically $25).

D2957 Additional prefabricated post. New Code

Along the same lines, if a prefabricated post and core buildup is indicated, and more than one post is required for retention, then the correct coding is D2954 for the first preformed P&C, followed on the next line of the claim by code D2957 for the second post, with the tooth number indicated and an additional fee.

Important description changes: All the above-mentioned codes are for single teeth only. If the identical procedure is performed on a bridge-abutment tooth, the codes are now completely different (see below).

ii. Tooth-supported prosthodontic treatment: crowns, posts, and cores on bridge-abutment teeth

D6970 Cast Post and Core, not part of crown. New Code

A cast post and core fabricated for a bridge abutment tooth, and separate from the actual crown/bridge abutment, is no longer coded using the same code as for an individual crown.

D6971 Cast Post and Core, part of crown. New Code

Along the same lines, if the cast post and core is an integral part of the bridge abutment and not a separate entity, this is the correct procedure code, in addition to the bridge abutment code.

D6976 Additional Cast Post. New Code

When an additional post is necessary for retention of the cast core, this code follows either code D6970 or D6971, with the tooth number indicated being the same as for these codes.

D6972 Pre-fabricated Post and Core. New Code

D6977 Additional Pre-fabricated Post and Core. New Code

These codes follow the same guidelines as cast post and cores, with D6977 following D6972 and using the same tooth number.

Important: If only a core buildup is indicated, do not use code D2950. The correct code is the New Code — D6973 Core Buildup on Bridge Abutment Tooth.

iii. Implant-supported prosthodontic treatment: crowns, bridges, and removable dentures

Most dental plans do not routinely cover implant supported crown and bridge services, or removable prosthodontics. However, regardless of whether or not the plan includes implant benefits, these planned procedures should be sent in for a pre- determination estimate, with a request for alternative benefits in order to maximize any plan benefits that the patient may have when implant-related services are not covered. The specific alternative benefits should be indicated by their CDT-4 code.

Implant abutments

D6056 Pre-fabricated Abutment. New Code

D6057 Custom Abutment. New Code

These new codes are self-explanatory. The code selected depends on the type of abutment used, either a stock abutment, or a custom-made one. The abutment is the portion of the implant superstructure that is screwed into the implant itself before the crown/bridge is then cemented/ screwed onto it. Abutments are not always used when superstructures are fabricated to fit onto the implant itself.

Implant crowns

The codes for the crowns fall into one of three categories:

D6058-D6064 Abutment-supported single-implant crowns. New Codes

These crowns fit onto implant abutments which screw into the implants themselves.

D6065-D6067 Implant-supported single-implant crowns. New Codes

These are crowns that fit directly into and onto the implant itself, typically screwed on, with no abutment component.

D6068-D6074 Abutment-supported implant bridge abutments. New Codes

These are crowns that fit onto the implant abutment and are the actual abutment to the bridge/superstructure.

D6075-D6077 Implant-supported implant bridge abutments. New Codes

Again, there is no interim abutment that fits into the implant. The crown is screwed into the implant itself.

Please note: The pontic codes remain the same as for a tooth borne bridge.

Implant-supported removable dentures

D6078 Implant-supported Removable Partial Denture. New Code

No longer should the traditional tooth-borne codes D5213/D5214 or D5861 be used.

D6079 Implant-supported Removable Complete Denture. New Code

Again, do not use the complete (D5110/D5120) or overdenture (D5860) codes.

Surgery

Only one minor code description revision for simple extractions has been implemented.

D7110 Single Tooth Extraction

This code is used for the first tooth removed in the quadrant.

D7120 Each Additional Tooth. Revised Description

For each additional tooth extracted in the same quadrant at the same visit.

For example, if teeth numbers 04, 05, 14, and 31 are all extracted during the same appointment, the correct coding would be:

04 — D7110 Simple extraction

05 — D7120 Additional extraction

14 — D7110 Simple extraction

31 — D7110 Simple extraction

Extraction of wisdom teeth: symptomatic or orthodontic indications?

Once considered routine procedures, the extraction of wisdom teeth is now anything but, under the current dental benefit packages. The removal of wisdom teeth is now considered a covered benefit only under very tight and restrictive parameters. They are divided into two categories: teeth removed because they are symptomatic or exhibit pathology and those that are recommended for removal by an orthodontist. The limitations on these procedures are as follows:

Wisdom teeth removed due to symptoms/pathology — These extractions are covered under the surgical portion of the dental contract, typically at the 80-percent allowable benefit level. It is imperative that the reason for the extraction(s) is stated in the "Remarks" portion of the dental claim form

Wisdom teeth removed for orthodontic reasons — These extractions are covered under the orthodontic portion of the policy and, as such, carry different restrictions than those listed above. In this category, the typical restriction is that the patient be under the age of 18. The coverage is also reduced to the orthodontic benefit level, commonly being 50 percent of the allowable benefit. Once again, it is necessary to state in the "Remarks" section that the teeth are being removed for orthodontic reasons.

In cases involving wisdom teeth that are impacted, it is highly recommended that these procedures be billed to the medical plan.

Desensitizing treatments

D9910 Application of Desensitizing Medicament. Revised Description

This code is used for the topical application of fluoride or other desensitizing medicament applied to the root surface. This is a "per visit" procedure and involves one or more quadrants. This code can only be used once per visit. In the "Remarks" section of the ADA claim form the medicament used should be indicated.

D9911 Application of Desensitizing Resin. New Code

This code, unlike the previous one, is reported on a "per tooth" basis for the application of adhesive resins and/or glass ionomer restorations to a caries-free root surface to treat sensitivity due to exposed dentin. It is not used to report liners or bases of restorations, which are included in the CDT-4 codes for those particular procedures.

Conclusion

It is critical that the billing staff continually update their knowledge of billing codes, especially now that HIPAA regulations have been implemented, requiring all offices and insurance companies to use only current ADA-recognized (CDT-4) codes in filing and processing claims electronically. It is also imperative, unless an extension was filed, that these codes were incorporated into the billing protocol for all claims, as required by law, effective Jan. 1, 2003.

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].