Dental Procedure Codes
The Good, The Bad, and The Ugly
Communication
“The language of reimbursement?”
Dental
Procedure
Codes!
Fee-for-service
Third Party Payers
Government Programs
Why a CDT Code?
Purpose –

Provide uniformity, consistency and specificity
in accurately reporting (i.e., documenting)
dental treatment
Use –


Populate patient health record – electronic
and paper
Provide for the efficient processing of dental
claims
4
History of Dental Codes
American Academy of Periodontology
introduced categories of services in 1967.
1969, Current Dental Terminology was
introduced, and published for the first
time in JADA.
The codes continued to be published in JADA
from 1972 through 1987.
The first condensed version of a Current Dental
Terminology (CDT) manual was in 1979, also
found in JADA.
In 1986, The ADA Council on Dental Benefit
Programs published the current version, in an
educational format
Dental Procedure Codes were designated under
the Health Insurance Portability Act (HIPPA) as
the national terminology for reporting dental
services recognized by third party payers
nationwide in 1996.
They are the most commonly used codes for
reporting dental procedures (other accepted
coding sets include ICD-9, and HCPCS)
What is a code?
A system of symbols (e.g., letters or
numbers) that represent assigned
meanings
Information that can be processed by a
computer without human intervention



D0150 is the dental procedure code that
means comprehensive oral examination
1223G0001X is the provider specialty code
for a dentist in general practice
01/01/2012 is the code that means the first
day in the month of January in the year 2012
8
Components of a CDT Code
entry
Procedure Code
Five character alphanumeric
beginning with “D”
Nomenclature (name)
Written title of the procedure
D0210 intraoral - complete series of
radiographic images
A radiographic survey of the whole mouth,
usually consisting of 14-22 periapical and
posterior bitewing images…
Descriptor (description)
Narrative providing further definition and intended use of the
procedure; most but not all codes have a descriptor
9
Categories of Service
I.
Diagnostic
D0100D0999
II.
Preventive
D1000VIII. Implant Services D6000-D6199
D1999
III. Restorative
D2000D2999
VII.
Maxillofacial
Prosthetics
D5900-D5999
IX.
Prosthodontics D6200-D6999
fixed
IV. Endodontics
D3000D3999
X.
Oral and
Maxillofacial
Surgery
D7000-D7999
V.
D4000D4999
XI.
Orthodontics
D8000-D8999
XII.
Adjunctive
General
Services
D9000-D9999
Periodontics
Prosthodontics
VI.
– removable
D5000D5899
10
The code manual’s technical content is the
responsibility of the Council on Dental
Benefits of the ADA.
This includes the glossary, format, and
content of the manual.
The Code Set
The actual code set found in the manual, is
changed through a process that includes
not only the Council on Dental Benefit
Programs, but also third party payers and
specialty organizations.
How are dental procedure codes
changed?
In 2000, a code revision committee was
established to update the code biannually.
It consisted of an equal number of
members from the Council on Dental
Benefit Programs and Third Party Payers,
such as Delta, MetLife and NADP.
Beginning in 2013, the process was
changed to provide more input by
establishing the Code Maintenance
Committee
There are 22 voting members of the CMC
including ADA members with code
experience, a representative from each
specialty organization and the Academy of
General Dentistry, and Third Party Payers.
Each member has one vote on the
committee
Also beginning in 2013, changes in the
code set will occur annually, rather than
biannually as in the past.
The 2014 edition of the CDT Manual
includes 641 dental procedure codes.
20 orthodontic codes
34 periodontal codes
132 oral surgery codes
Changes in the Code
Any person, group, or organization can
request a change in the dental procedure
codes.
Changes are classified as new codes,
deleted codes, or code revisions.
(ADA Use Only)
CDT Code – Code Action
1.
Requestor Information
Date Submitted:
Name:
Address (Line 1):
Address (Line 2):
City:
State:
Telephone:
2.
Email:
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 >
No >
3.
Zip Code
If Yes,
Name:
Does the requestor or entity identified in item #1 or #2 receive any financial benefit?
Yes >
No >
If Yes,
describe:
Add
Revise
Affected Code (Revisions & Deletions)
4.
Action
Delete
5.
Full text of requested action (Additions & Revisions)
D
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?
9.
Yes >
No >
Protected by
copyright?
Additional Comment/Explanation:
Yes >
No >
Permission to
reprint?
Yes >
No >
Guidelines for changes:
Requests should be based on the need to accurately
document procedures performed.
They should be concise, clear, and not ambiguous.
Time limitations should not be included.
Unbundling or fragmenting an existing procedure into it’s
component parts is not permitted.
It should refer to a procedure and not a specific trade
name, technique, or instrumentation
Requests pertaining to newly developed procedures are
encouraged to include documentation of clinical efficacy.
In Actuality:
When being considered, there are a few things
that strengthen the request:
Is the procedure taught in dental schools?
Is there literature to support the request?
Are there multiple requests?
Is it requested and/or supported by CDBP
and specialty organizations?
Timeline for the Code Revision
Process
Closing date for submitting a request is
November 1.
The Code Maintenance Committee meets
in February-March the following year.
Decisions are sent out to requestors in
early April and posted on ADA.org for
public information
Preparation of CDT Manual for following
year is complete by early May.
Changes effective – 01/01/2013
161 code change requests
submitted for consideration
35 Additions in 8 categories
37 Revisions in 9 categories
12 Deletions in 4 categories
21
New Periodontal Codes 2013
Previously, the code for a free gingival graft:
4271 Free soft tissue graft procedure,
(including donor site surgery)
Beginning in 2013, the codes are:
4277 Free soft tissue graft procedure (including
donor site surgery), first tooth or edentulous
tooth position in graft
4278 Free soft tissue graft procedure (including
donor site surgery), each additional contiguous
tooth or edentulous tooth position in same
graft site
What’s on the horizon?
Codes for procedures using lasers (???)
Expanding current codes to allow use of
new materials (e.g. GINTUIT, etc)
????????????????????????????????
AAP Involvement
Division of Public, Practice, and Scientific
Affairs
Patient Benefits and Advocacy
Committee
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 Committee
ADA Standards Committee on Dental
Informatics
SNODENT
ICD-9 and ICD 10
Dental Quality Alliance
Code Maintenance Committee
Represents AAP interests in coding: Insurance
Consultant represents AAP at table
Decisions are made through a process that involves the
AAP Insurance Consultant, Patient Benefits and
Advocacy Committee, and the Board of Trustees.
Consults with third party carriers and has input from
membership for code revisions
ADA Standards Committee on
Dental Informatics
Representation on committee establishing
parameters and standards for electronic
communication
Determines requirements for standardization
of claims submission for electronic
submissions
SNODENT
Has input for periodontal diagnostic codes
developed by the ADA
Monitors updates and changes
ICD-9 and ICD-10
HCPCS
Monitors updates and changes for medical
diagnostic (ICD-9) and procedure codes
(HCPCS) applicable to periodontics.
ADA claim form – Diagnosis
Codes
Diagnosis Code Pointer
ICD-9-CM Diagnosis
Code (at least one)
30
Dental Quality Alliance
Voting member of alliance to develop quality
measurements for the dental profession
Educational Opportunities
Annual Meeting Insurance Workshops:
Dental and medical coding
for reimbursement
State and Regional Insurance
Workshops
AAP Complaint Resolution Process
Designed to provide assistance for coding
and 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 statistics
AAP received 1352 and 1287 calls in 2011 and
2012 respectively that involved the complaint
resolution process.
In the last two years, it has resulted in over
$50,000 in additional benefits for members and
patients
In 2012, over 250 calls were received regarding
medical benefits
Additional member services as
result of the complaint resolution
process:
Facilitation of EOB language complaints
Face-to-face meetings with third party
dental directors to discuss issues including
benefits and plan details
Resolution of administrative issues with
third party payers
The complaint resolution process not only
provides a unique service for members,
but also encourages communication
between the specialty and third party
payers. Many times the Academy is
consulted regarding policies, interpretation
guidelines, and other administrative
decisions.
So how does this fit into residency
programs?
Beginning a practice or joining a
group practice can be
overwhelming:
Fee-for-service vs contractual plans
Participant vs Non-participant
Contract analysis
Residents need practice management resources
when they begin practice:
-Recognizing the importance of dental procedure coding in
clinical practice
-How to submit for reimbursement, saving time and money
-Receiving optimal reimbursement
-Troubleshooting insurance problems
-Electronic filing
Best Practices for the Periodontist
Ethical
Guidelines for care
Legal responsibilities
What can the AAP do to help?
What materials can the AAP provide to
programs?
What is the best method of delivering the
information?
How and when can it be best integrated
into programs?
Some ideas
Annual meeting workshop for residents on coding and
third party issues?
Webinars over the course of the year to introduce
residents to these practice management issues?
Support for faculty to integrate third party issues into the
curriculum?
We are a
wealth of
information!