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Part I of II - CDT-4 revisions, deletions, and new codes

The CDT-4 became effective in January 2003 and remains in effect until December 2004. The CDT-5 is currently being prepared, with revisions to codes, code deletions, and new codes to be added, and will become effective in January 2005. The first article in this two-part series will address the changes which appeared in the CDT-4 and are currently in effect, as well as anticipated code additions that will appear in CDT-5. The second part will appear in a future issue of Dental Equipment & Materials and will deal with code changes, additions, revisions, and deletions appearing in CDT-5. Current information and updates are always available through www.ada.org/goto/dentalcode.

Summary of changes in the CDT-4 code book

. Deleted codes

1. Diagnostic
2. Histopathologic Examinations: D0501
3. Restorative
4. Amalgams on Primary Teeth: D2110, D2120, D2130, D2131
5. Resin-based Crowns on Anterior Teeth: D2336, D2337
6. Composites/Primary Posterior Teeth: D2380, D2381, D2382
7. Composites/Permanent Posterior Teeth: D2385, D2386, D2387, D2388
8. Periodontics
9. Gingival Curettage: D4220
10. Fixed Prosthodontics
11. Inlays/Onlays: D6519, D6520, D6530, D6543, D6544
12. Oral Surgery
13. Simple Extractions: D7110, D7120, D7130
14. Removal of Lesions/Tumors: D7420, D7430, D7431
15. Partial Ostectomy: D7480

. Revised nomenclature (revisions/additions to nomenclature are in italics)

1. Diagnostic

D0150 Comprehensive Oral Evaluation-New/Established Patient - Typically, only two examinations per year (in the diagnostic category) are covered under the dental contracts. Some contracts specify only one examination every six months. This includes any type of exam - D0120, D0140, D0150, D0160, D0170, D0180.

2. Restorative

Replacement of restorations due to recurrent decay or failure of the restoration is typically limited to once every three years under most dental contracts. If a dentist is a contracted provider, he or she is not allowed to “balance bill” for the portion of the cost that is not covered by the plan. In addition, some plans allow payment for only a one-surface restoration, regardless of how many surfaces were restored!

D2140 1-Surface Amalgam, Primary or Permanent Tooth

D2150 2-Surface Amalgam, Primary or Permanent Tooth

D2160 3-Surface Amalgam, Primary or Permanent Tooth

D2161 4+ Surface Amalgam, Primary or Permanent Tooth

Typical crown benefits for the replacement of an existing crown range from five to seven years before a replacement crown payment will be permitted. Some plans are now allowing only one crown per tooth, with no replacement benefit. Therefore, once a crown has been paid for under the contract, any replacement crowns in the future will not be covered and will be paid for out-of-pocket by the patient. An esthetic/porcelain surfaced crown will often not be a payable benefit on a molar tooth if cosmetic procedures are not a covered benefit of a dental plan.

D2710 Crown-Resin Indirect - This includes crowns such as Targis/Vectris®, Sculpture/ FibreKor®, Artglass®, BelleGlass®, and the like.

3. Endodontics

D3221 Pulpal Debridement, Primary or Permanent Tooth - Paid to the general dentist that will not be completing the endodontic treatment. Considered part of the procedure if the same dentist performs this procedure and the subsequent endodontic therapy.

4. Periodontics

Note the minimum number of teeth considered in the following procedure codes:

D4210 Gingivectomy or Gingivoplasty- 4+ Teeth or Bounded Spaces, per Quadrant

D4240 Gingival Flap Procedure, including Root Planing, 4+ Contiguous Teeth or Bounded Teeth Spaces, per Quadrant

D4260 Osseous Surgery (including Flap Entry and Closure) 4+ Contiguous Teeth or Bounded Teeth Spaces, per Quadrant

D4273 Sub-epithelial Connective Tissue Graft Procedure

D4341 Periodontal Scaling and Root Planing, 4+ Contiguous Teeth or Bounded Teeth Spaces, per Quadrant

D4355 Full Mouth Debridement to enable Comprehensive Evaluation and Diagnosis - Note the condition stipulated for this code. This code can be used prior to D4341, D4342, D1110, and any examination/evaluation code but cannot be used on the same date of service. Many dental plans do not cover this procedure and patients should be informed of this. Some carriers pay for this code as a once-in-a-lifetime benefit, while others downcode it to a D1110. The fee for this procedure is typically the same, or close to that for D4910.

D4910 Periodontal Maintenance - Does not include the periodontal evaluation and this may be billed separately using code D0180 or, alternatively, D0120. It should also be noted that the typical dental contract does not cover the examination codes when billed in conjunction with D4910, even though they can legitimately be billed. Thus, the patient is responsible for payment of the examination. The fee associated with the D4910 procedure code is 1.5-2 times that for D1110.

5. Oral surgery

All of these surgical procedures should be billed to the medical plans in order to maximize patient benefits. The appropriate medical diagnosis (ICD-9) and procedure (CPT) codes must be entered on the medical claim form (HCFA-1500). Do not submit information to medical carriers on a dental claim form. If the office elects to submit these oral procedures to the dental plan, then note the revised nomenclature for each code.

D7270 Tooth Reimplantation and/or Stabilization of Accidentally Evulsed or Displaced Tooth - Treatments associated with traumatic injury should always be billed to the medical plan

D7280 Surgical Access of an Unerupted Tooth - Typically covered under the orthodontic portion of the dental policy

D7291 Transseptal/Supra-Crestal Fiberotomy - Typically covered under the orthodontic portion of the dental policy

D7410 Excision of Benign Lesion up to 1.25 cm

D7450, D7451, D7460, D7461 Removal of Benign Odontogenic Cyst/Tumor

D7471 Removal of Lateral Exostosis (Maxilla/Mandible) - This refers to buccal exostoses only

D7530 Removal of Foreign Body from Mucosa, Skin, or Subcutaneous Alveolar Tissue

D7550 Partial Ostectomy/ Sequestrectomy for Removal of Non-Vital Bone

D7670 Alveolus- Closed Reduction May Include Stabilization of Teeth

D7770 Alveolus-Open Reduction Stabilization of Teeth

6. Additional general

Anesthesia benefits are typically covered only for patients that are handicapped and also for children under 14. They may also be available for certain surgical procedures. The office should consider billing anesthesia services to the medical plan. Regarding nitrous oxide sedation, this is not usually a covered benefit for routine dental procedures under any dental plan. It may be a benefit for certain difficult or unusual surgical procedures.

D9220 Deep Sedation/General Anesthesia-First 30 minutes

D9221 Deep Sedation/General Anesthesia-Each additional 15 minutes

D9241 Intravenous Conscious Sedation/Analgesia-First 30 minutes

D9242 Intravenous Conscious Sedation/Analgesia-Each additional 15 minutes

For intravenous and general anesthesia procedures, it is recommended that the anesthesia record be attached to the claim form.

. New codes

1. Diagnostic

D0180 Comprehensive Periodontal Evaluation - Typically paid only to periodontal offices for extensive periodontal evaluations. A periodontal evaluation is considered part of code D0150 when performed by a general dentist. These codes are not billable with the same date of service. This code can also be used in conjunction with periodontal maintenance visits (code D4910). This service is part of the Periodic Exam and cannot be billed together with code D0120.

2. Restorative

D2390 Resin-based Composite Crown-Anterior

It is anticipated that the dental contracts will reimburse the following codes to the same extent as they would have for an amalgam of similar size on the same tooth.

D2391, D2392, D2393, D2394 Resin-based Composite Restoration-Posterior Tooth-Primary or Permanent

D2391 1-Surface

D2392 2-Surface

D2393 3-Surface

D2394 4-plus Surface

3. Periodontics

When submitting claims for periodontal procedures, it is strongly advised that the claim contain information regarding the type of disease process present. Even though a Classification of Periodontal Diseases and Conditions has been set forth by the American Academy of Periodontology (December 1999), it is recommended that the following simpler, previously implemented, classification system be used instead:

Case Type I - Gingivitis - Characterized by bleeding, change in contour, purulent discharge. No bone loss present.

Case Type III - Moderate Periodontitis - Increasing bone loss. Some tooth mobility (1, 1+). Furcation involvement, but not through and through. Pocket depths 5-6 mm.

Case Type IV - Advanced Periodontitis - Severe bone loss. Tooth mobility (2, 2+, 3). Furcation involvement through and through. Probing depths 7+ mm.

Case Type V - Refractory Periodontitis - Bone loss and disease continue despite aggressive therapy. May be in single sites or throughout the mouth.

It is also recommended that all periodontal claims include charting and radiographs for the quadrant to be treated, regardless of whether these would indicate the problem or not. It is also highly advisable to include intraoral photographs of the areas requiring soft-tissue surgical procedures.

D4241 Gingival Flap Procedure, including Root Planing-1-3 Teeth, per Quadrant - This procedure is typically allowed in areas where the pocket probings are in the 5-6 mm range, indicating Case Type III periodontal disease. Pre-determination of benefits is recommended for this code.

D4261 Osseous Surgery (including Flap Entry and Closure) 1-3 Teeth, per Quadrant - Most plans allow only for code D4260 and patients should be told that there is a strong possibility that treatment of a partial quadrant will not be covered. Pre-determination of benefits is recommended for this code.

D4265 Biologic Materials to Aid in Soft Tissue Regeneration - Most plans consider this part of the overall surgical procedure and will not pay separately for it. However, a brief narrative written in the “Remarks” section of the claim form may result in payment.

D4275 Soft Tissue Allograft - Most plans allow for this procedure with similar benefits to code D4271 Free Soft Tissue Graft Procedure.

D4276 Combined Connective Tissue Double Pedicle Graft - Carriers consider this procedure using the same guidelines as for D4270, D4271, and D4273.

D4342 Periodontal Scaling and Root Planing - 1-3 teeth, per Quadrant

As for code D4341, this code typically is allowed for Case Type III or higher. Indicate this on the claim form. The same documentation requirements apply.

4. Removable prosthodontics

D5670 Replace all teeth and Acrylic on Cast metal Framework (Maxillary)

D5671 Replace all teeth and Acrylic on Cast metal Framework (Mandibular)

Partial and full denture replacements are allowed every five to seven years for most carriers, although some extend this to 10 years. If the replacement of the teeth will allow the denture to last through this life span, then this benefit may be allowed. This comment should be indicated in the “Remarks” section of the dental claim form. A replacement denture will not be allowed sooner than the seven- or 10-year time frame if this benefit has been allowed.

5. Implant services

Should a patient have coverage for implant-related services under his or her dental plan, coverage for an implant-supported prosthesis will typically be limited to that for a traditional partial or full denture. All implant-related prosthetic services should be sent in for predetermination of benefits, requesting alternative benefits should there be no coverage for implant-borne prosthetics.

D6053 Implant/Abutment Supported Removable Full Denture

D6054 Implant/Abutment Supported Removable Partial Denture

6. Fixed prosthodontics

*Inlays

Porcelain/Ceramic (D6600 1-Surface, D6601 2-Surface)

High Noble Metal (D6602 2-Surface, D6603 3+Surface)

Predominantly Base Metal (D6604 2-Surface, D6605 3-plus Surface)

Noble Metal (D6606 2-Surface, D6607 3-plus Surface)

* Onlays

Porcelain/Ceramic (D6608 2-Surface, D6609 3-plus Surface)

High Noble Metal (D6610 2-Surface, D6611 3-plus Surface)

Predominantly Base Metal (D6612 2-Surface, D6613 3-plus Surface)

Noble Metal (D6614 2-Surface, D6615 3-plus Surface)

* Provisional Bridges (D6793 Provisional Retainer Crown, D6253 Provisional Pontic)

Benefits for a traditional fixed bridge are payable every five to seven years, depending on the contract. A provisional bridge is fabricated as an interim restoration while other ongoing work is completed (periodontal therapy, implant surgery, etc.). Should a provisional be needed, it is expected to be lab-fabricated and to remain in place for a period of not less than six months. Typically the benefit for this procedure would be deducted from the benefit for the final restorations. However, all too often, there are no benefits payable at all. Check with the benefits department for the particular plan, or send in a claim for the predetermination of benefits. Make sure that the patient, as always, is informed of the possibility of no coverage before proceeding.

* D6985 Pediatric Fixed Bridge- considered an esthetic procedure because it is fabricated for the anterior teeth only. Currently not a covered benefit under most plans.

Important change coming up in CDT-5: There will be additional codes added for fixed and removable prosthodontics that will break the procedures down into their component parts. This means that there will be separate codes for the preparation, impression, and delivery portions of each procedure.

7. Oral surgery

It is strongly recommended that surgical procedures involving incisions - surgical removal of tissue, closure of fistulas or perforations, removal of pathologic lesions by biopsy or excision - be billed to medical plans, since coverage and payment is faster and reimbursement better. It is more beneficial to the patient to save the dental plan benefits for procedures that would only be covered under a dental plan.

D7111 Extraction of Coronal Remains-Deciduous Tooth - This procedure code should be used for the removal of a deciduous tooth that has already undergone some root resorption but has not fallen out. Coverage is expected under most dental plans, although at a much lesser fee than a simple extraction.

D7140 Extraction, Erupted Tooth or Exposed Root - For primary or permanent teeth. Coverage is expected to be the same as that previously allowed for the (now deleted) codes D7110/D7120. The billed fee should be comparable to a simple extraction of a permanent tooth.

D7261 Primary Closure of Sinus Perforation - Should a sinus perforation occur during an extraction, this code should be billed in addition to the extraction code. It is expected that most plans will consider this as part of the extraction code. If there is an oroantral fistula, then the code D7260 Oroantral Fistula Closure should be used. This code implies closure using an advancement flap and would be covered under most dental plan provisions.

D7282 Mobilization of Erupted or Malposed Tooth to Aid Eruption - Used when the forceps luxation of a tooth is indicated to prevent/eliminate ankylosis.

D7287 Cytology Sample Collection - This code is to be used for the recently developed “brush biopsy” techniques and can also be used for the scraping of oral soft tissues for analysis. This code should be billed with D0480 Processing and Interpretation of Cytologic Smears. There is currently no history as to payment on this code.

* Excision of Lesions

Benign (D7411 lesion >1.25 cm., D7412 Complicated)

Malignant (D7413 lesion <1.25 cm., D7414 lesion >1.25 cm., D7415 Complicated)

*Excision of Bone Tissue (D7472 Torus Palatinus, D7473 Removal of Torus Mandibularis, D7485 Reduction of Osseous Tuberosity)

Conclusion

The final published version CDT-4 included many code changes. Federal law (HIPAA) necessitates that private offices and insurance companies all implement these codes when filing and processing dental claims electronically. It is imperative that the business staff, as well as the office billing software, be current so that not only are claims processed more rapidly and accurately, but that the office be in HIPAA compliance, as required by law.

Dr. Olya Zahrebelny is in private fee-for-service practice in the Lincoln Park area of Chicago, has taught at three dental schools, and practiced in both hospital and private practice settings. Dr. Zahrebelny has lectured extensively at all major meetings throughout the United States, for graduate and continuing-education programs and, through The Z Group, LLC, provides in-office consulting services. 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 request at [email protected].