Download Why Do CDT Codes Exist? - California Society of Pediatric Dentistry

AAPD Coding and Insurance Workshop
Mary Essling
AAPD Dental Benefits Manager
California Society of Pediatric Dentistry
Rancho Mirage, CA
April 28 , 2013
Why Do CDT Codes Exist?
• Purpose
 Provides uniformity, consistency and specificity in
accurately reporting/documenting dental treatment
• Use
 Populates patient health record — electronic and paper
 Provides for efficient processing of dental claims
1
CDT Basics
D1351
Code Number
Sealant – per tooth
Nomenclature
Mechanically and/or
chemically prepared
enamel surface sealed
to prevent decay
Descriptor
CDT Basics
 Code for what you do, not what you are paid for.
 Just because a code exists does not mean that it may
be a paid benefit or covered service in a dental
insurance plan
2
Decisions
 Current Dental Terminology (CDT) maintained by
the ADA Code Maintenance Committee (CMC)
 Twenty-one members
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5 ADA Members (one will serve as Chair)
9 Reps from each of specialty organizations
1 Rep from AGD
5 Reps from third-party payers
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DDPA (Delta Dental Plans of America)
AHIP (America’s Health Plans of America)
CMS (Centers for Medicare and Medicaid)
BCBS (Blue Cross Blue Shield Association)
NADP (National Association of Dental Plans)
 1 Rep from ADEA (American Dental Education Association)
Code Revision Process
 Contact AAPD Dental Benefit Manager
 May be able to suggest alternative code
 May have suggestions on proper submission of existing
code
 May have idea of need based on number of calls
 Contact your AAPD District Representative — Dr.
Reggiardo
3
Code Revision Process
 CDBP District Representatives
 Eli Schneider (I)
 Katherine Wezmar Poepperling (II)
 Ashley Patnoe (III)
 Brent D. Johnson (IV)
 Brynn Leroux (V)
 Paul Reggiardo, Chair (VI)
Code Revision Process
 Review by AAPD Important
 Annual Review starting in 2013
 Submit completed form to AAPD staff
 Council can suggest wording to improve chance of
passage
4
CDT 2013
Changes Effective
January 1, 2013
 36 new codes
 37 revised codes
 12 deleted codes
Classification of Materials
Relocated to precede all categories of service
Revised descriptor for Porcelain/Ceramic material:
Refers to pressed, fired , polished or milled
materials containing predominantly inorganic
refractory compounds including porcelains,
glasses, ceramics and glass ceramics.
This language now covers new materials that did not
fit into the previous description of
porcelain/ceramic materials.
5
Diagnostics – Major Actions
 Revision and expansion of Diagnostic Imaging
subcategory
Evolutionary changes to imaging
modalities
 New subcategory for Pre-diagnostic Services
Regulatory changes for increased patient
access to care
Diagnostic Imaging – 3 Subsubcategories
 Image capture with interpretation
 Continuing image capture and interpretation
(e.g., FMX; BWX) within the dentist’s office
 Image capture only
 Separate facilities for MRI, Ultrasound and other
special imaging
 Interpretation and report only
 Practitioner s who specialize in analyzing
diagnostic images
6
Change “film” to
“radiographic image”
 “Film” is out of date
 All nomenclature with “film” revised
 Example –
 Before change:
 D0270 bitewing – single film
 As revised
 D0270 bitewing – single radiographic image
Pre-diagnostic Services
 D0190 — screening of a patient
A screening, including state or federally mandated
screenings, to determine an individual’s need to be seen
by a dentist for diagnosis.
 D0191 — assessment of a patient
A limited clinical inspection that is performed to identify
possible signs of oral or systemic disease, malformation,
or injury, and the potential need for referral for diagnosis
and treatment.
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Preventive – One for two
 One addition to replace two deletions
o New:D1208 topical application of
fluoride
o Deleted: D1203 and D1204
 Why?
o Topical fluoride (gel, foam) is applied
in same manner for both dentitions
Preventive – One revision
Before change:
As revised:
D1206 — topical fluoride
varnish: therapeutic
application for moderate to
high caries risk patients
D1206 — topical application of
fluoride varnish
Application of topical fluoride
varnish, delivered in a single
visit and involving the entire
oral cavity. Not to be used for
desensitization.
Why?
No reason why varnish
application should be
constrained by level of caries
risk.
8
Restorative Highlighting 2 revisions
D2940 — protective restoration
 Removed “temporary” from qualifier so that it
can be used as more definitive restoration such
as ITR.
 There will be a new ITR code in 2014. AAPD was
instrumental in getting this passed
Restorative Highlighting 2 revisions
• D2990 — resin infiltration of incipient
smooth surface lesions
Placement of an infiltrating resin restoration for
strengthening, stabilizing and/or limiting the
progression of the lesion.
• D2929 — prefabricated
porcelain/ceramic crown – primary tooth
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Restorative Highlighting 2 revisions
OLD
D2799 provisional crown
Crown utilized as an interim
restoration of at least 6 months
duration during restorative
treatment to allow adequate time
for healing or completion of other
procedures. This includes, but is not
limited to changing vertical
dimension, completing periodontal
therapy or cracked tooth syndrome.
This is not to be used as a
temporary crown for a routine
prosthetic restoration.
 No more arbitrary time
criteria required
D2799 provisional crown –
further treatment or
completion of diagnosis
necessary prior to final
impression.
Not to be used as a
temporary crown for a
routine prosthetic
restoration.
Adjunctive General Services
Addition
D9975 — external bleaching for home application,
per arch: includes materials and fabrication of
custom trays
Revision
D9972 — external bleaching – per arch - performed
in office
10
Preventing Claim Errors
Unintended errors are most often caused by
misunderstanding or misinformation
Right Codes for Dental
Claims
Primary code source for pediatric dental
claims:
AAPD Coding and Insurance CD ROM 2013
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No code to describe a
procedure?
Unspecified ….procedure by report codes are:
 For those situations where, in the opinion of the
dentist, none of the entries in the CDT Code
accurately describe the services provided
 They are in each category of service except for
Preventive (2014 will have a 999 code)
Avoiding procedure
coding errors
By report - A clear and concise narrative should include:
 Clinical condition of the oral cavity
 Description of the procedure performed
 Specific reason why the extra time or material was
necessary
 How new technology enabled procedure delivery
 Any specific information required under a participating
provider contract
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By report codes
 A third-party payer is likely to return the entire
claim if the narrative is missing
 Even when the narrative is present, the carrier
may request additional information
New codified data
Up to four diagnoses may be reported for each procedure on a
claim
 Reporting is discretionary
 May be reported on the HIPAA standard electronic dental
claim and the ADA’s paper claim form
Codes used in the public domain
 ICD-9 CM (now)
 ICD-10 (2014 or 2015)
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Coding for Reimbursement
Q: What codes have the best chance for reimbursement
A: Codes for procedures that are covered by the patient’s
dental benefit plan
Your treatment plan should be based on the patient’s
clinical needs and NOT the covered procedures!!!!
Coding for Reimbursement
The Facts of Life –
 Not all procedures are covered
 Some have annual or lifetime limitations
 Limitations and exclusions can vary between plans offered
by the same company
 HIPAA only requires that a payer accept a valid procedure for
processing
 HIPAA does not require that a payment for every procedure
in the CDT Code
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Determining the
Date of Service
Q: When there is a single code for a procedure that
requires multiple appointments, how do I determine
the date of service?
 ADA policy for fixed and removable prosthetic
cases encourages payers to use the date of
impression as the date of service
 Some state laws and third party processing policies
and contract provisions specify completion date as
the date of service
Determining the
Date of Service
 Weigh all of these factors when determining date of
service reported for the procedure code
 Be consistent and compliant with policy, regulations
and contract provisions
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Claim Coding Confusion
There may be many reasons why a dentist or
staff may be unsure about the procedure code
to use:
 Infrequent delivery of the procedure
 Conflicting information from peers or thirdparty payers
Guidance is based on the published procedure
code nomenclatures and descriptors
Consultation Or Evaluation?
When is it appropriate to code for a consultation
(D9310) versus an evaluation e.g., D0140)?
A consultation occurs when Dentist A refers a patient
to Dentist B for an opinion or advice on a particular
problem
 Dentist A reports the appropriate oral evaluation code
 Dentist B reports the consultation code D9130
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Panoramic + BWXs = FMX?
 Panos and BWXs are NOT considered to be an FMX
 A full mouth series (aka FMX) is defined in the
descriptor of D0210 intrqaoral, complete
series….”
 A set of introral radiographs usually consisting of
14 to 22 periapical and posterior bitewing images
intended to display the crowns and roots of all
teeth, periapical areas and alvelar bone crest.”
Panoramic + BWXs = FMX?
 Third party payers sometimes bundle claims for
the pano and bitewing(or pariapical) images and
calculate reimbursement using the FMX D0210
fees
 The ADA considers this a potentially fraudulent
practice that should be appealed because”
 D0210 reimbursement is likely to be less that amounts
paid for pano and other images
 Bundled payment could lead to denial of a later D0210
claim due to plan limitations.
 Records of service rendered will be inaccurate
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Product vs. Procedure
Procedure codes are not product-specific or
brand name-specific
Occlusal pits and fissures
 When mechanical enlargement of occlusal pits
and fissures is performed in conjunction with
placement of a dental sealant, this preparation
step is not reported separately
 D1351 descriptor includes the preparation
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Occlusal pits and fissures
with decay
 When decay that does not extend into the dentin is
present code for D1352
 D1352 — preventive resin restoration in a moderate
to high caries risk patient — permanent tooth
 Conservative restoration of an active cavitated lesion
in a pit or fissure that does not extend into dentin;
includes placement of a sealant in any radiating noncarious fissures or pits
Occlusal pits and fissures
with decay
 The continuum ends with a third procedure code that
is appropriate when decay extends into the dentin
 D2391 — resin-based composite — one surface,
posterior
 Used to restore a carious lesion into the dentin or a
deeply eroded area into the dentin. Not a preventive
procedure.
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Local Anesthesia
 How may I report local anesthesia as a separate
procedure?
 D9215 local anesthesia in conjunction with operative
or surgical procedures is the procedure code for
separate reporting
 Benefit plan limitations and exclusions may preclude
separate reimbursement for local anesthesia
 Participating providers are likely unable to bill patients
when anesthesia is not reimbursed
Two 2 Surface Restorations
on Same Tooth
 Should I report a DO and an MO on the same
tooth as an MOD as carriers tell me?
 No….you should report D2150 twice...one for the
MO and one for the DO
 Some plans limit coverage when the same surface is
involved more than once on the same tooth and date and
they may apply an alternate benefit based on the fee for
a single restoration.
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Lasers
 CDT codes are procedure based
 Makes no difference in coding what
instrumentation is used to achieve the result
IRM Sedative or Palliative
 D2940 (protective restoration) is used for many
reasons, including pain
 D9910 (palliative treatment) is only for emergency
treatment of dental pain
 Only one of the codes can be reported
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Unfinished procedures
 How to report a situation where a procedure is
started but not finished
 CDT does not have codes for incomplete procedures
 Use D2999 for unfinished procedures along with a
narrative
When claim is denied
 The existence of a code does not mean that the
procedure is a covered or reimbursed benefit
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OK or NOT OK?
 NOT OK — you report D1110 and payer says you
should report D1120 for reimbursement
 Patient is 13 with predominantly adult dentition
and plan design defines adult to be 15 years of
age
 OK — for payer to accept D1110 and pay at D1120
based on plan design
OK or NOT OK?
 You report D0120, D1120 and D1208
 Payer says that these are not separate
procedures
 Payer says all three are part of D0120
NOT OK –
Payer is redefining D0120
Payer may be bundling
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OK or NOT OK?
 EOB to patient shows different codes than were
submitted by your office
 Claim form: D0120 and D1110
 EOB: D0120 and D1120
 Message says that these are the correct
codes for child pxs
 NOT OK: payer implication is that dentist
reported incorrectly
Preventing and Resolving
CDT Code Errors
 Prevention is always best
 Questions concerning proper coding should be
addressed as the claim is prepared
 There should be quality review before
submission
• Otherwise payer rejects the claim or sends back
requesting additional info
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Preventing and Resolving
CDT Code Errors
 Questions about accuracy?
 Use CDT Manual as your guide
 Ask dentist who performed the service
Preventing and Resolving
CDT Code Errors
 Contact Mary Essling at 312-337-2169 or email
[email protected]
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Preventing and Resolving
CDT Code Errors
 Review returned or denied claims to endure that
the proper codes were submitted
 If coding error, prepare and submit the corrected
claim
 When no coding error, prepare an appeal if
appropriate
Payer Error Should Be
Appealed
 Patient is 13 years old with predominantly adult
dentition
 Payer instructs you to bill D1120 for child pxs
because plan design defines child up to age 15
 Payer is asking you to miscode
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Payer Error Should Be
Appealed
 You report D0120, D1120 and D1203 but the
payer says these are not separate procedures
 Payer is ignoring the descriptors and redefining
procedure code – this is a copyright violation
 Payer is bundling – potential fraudulent act
Contract Provisions
and Limitations
 Contracts include limitations and exclusions such
as:
 Child prophy reimbursed thru age 15
 No more than two D4910 procedures per
calendar year
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Contract Provisions
and Limitations
 What does the contract say?
 What are your par provider contract provisions?
Did you agree to the LEAT clause?
 Dentist who signs a par provider contract is
bound to its legally sound provisions. KNOW
WHAT YOU ARE SIGNING!
ADA Paper Claim Form
 Latest version effective July 2012
 Key change is ability to report ICD-9 diagnosis
codes (Box 34)
 Comprehensive instructions on ADA.org
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Fractured Tooth – After
Hours Visit
 Patient presents to office on day when office is
closed
 Dr. performs:
 D0140 — limited oral evaluation — problem
focused
 D2970 — temporary crown (fractured tooth)
 D9440 – office visit — after regularly
scheduled hours
Note the Difference
D1351 — A sealant placed on the enamel surface to
prevent decay. The enamel surface is non-carious.
D1352 — A conservative restoration of an active
cavitated lesion in a pit or fissure, which does not
extend into dentin — also includes placing a sealant in
any radiating non-carious fissures or pit.
D2391 — A one-surface posterior composite restoration
where the caries and preparation extend into the
dentin or a deeply eroded area into the dentin.
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Preventive Resin
Restoration
Documentation Critical
 Detailed documentation is critical to avoid healthcare fraud!!
 For example, if you performed a PRR on tooth #30, record in
patient’s chart – caries removed, lesion extended 2mm into the
enamel (not into the dentin) and was restored by using
_____(material used).
 Same goes for a restorative code…document that decay into
dentin was removed.
 Front desk billers must pay close attention to documentation to
catch or correct errors and bill appropriately
KEY REVISIONS FOR
2011/2012
Revise - Sedative filling D2940
Revise nomenclature as follows:
 D2940 protective restoration
Revise Descriptor as follows:
 Direct placement of a temporary restorative material to protect tooth
and/or tissue form. This procedure may be used to relieve pain,
promote healing, or prevent further deterioration. Not to be used for
endodontic access closure, or as a base or liner under a restoration.
 Use for ART — Alternative Restorative Treatment
 Not only to relieve pain – broader scope now
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Requesting a New Code for
2013 — ITR
Interim Therapeutic Restoration
 Placement of an adhesive restorative material after removal of
caries by hand or slow speed rotary instrumentation to restore
and prevent further decalcification and caries in young precooperative or uncooperative patients, patients with special
healthcare needs, or when traditional cavity preparation and/or
placement of traditional dental restorations are not feasible and
need to be postponed.
 Current Code D2940 is not appropriate when using glass ionomer
materials and is not considered temporary.
KEY REVISIONS FOR 2011/2012
Revise Subcategory Title
Apexification/Recalcification and Pulpal
Regeneration Procedures
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KEY REVISIONS FOR 2011/2012
Revise Nomenclature and Descriptor
 D3351 — apexification/recalcification/pulpal
regeneration — initial visit (apical
closure/calcific repair of perforations, root
resorption, pulp space disinfection, etc.)
Includes opening tooth, pulpectomy, preparation
of canal spaces, first placement of medication
and necessary radiographs. (This procedure may
include first phase of complete root canal
therapy.)
KEY REVISIONS FOR 2011/2012
Revise Nomenclature
 D3352 — Apexification/recalcification/pulpal
regeneration — interim medication replacement
(apical closure/calcific repair of perforations,
root resorption, pulp space disinfection, etc.)
For visits in which the intra-canal medication is
replaced with new medication and necessary
radiographs. There may be several of these visits.
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KEY REVISIONS FOR 2011/2012
New Code
 D3354 — Pulpal Regeneration – completion of
regenerative treatment in an immature
permanent tooth with a necrotic pulp; does not
include final restoration
Includes removal of intra-canal medication and
procedures necessary to regenerate continued
root development and necessary radiographs.
This procedure includes placement of a seal at
the coronal portion of the root canal system.
Conventional root canal treatment is not
performed.
Pulpal Regeneration
Procedures
 D3351 — Initial visit to open the tooth, prepare the canal
spaces, and place the initial medication
 Includes working radiographs
 D3352 — Additional pulp disinfection procedures and
interim medication replacement
 May require multiple visits…each reported as D3352
 D3354 — Final visit may involve re-entering the tooth,
irrigating the root canal system, re-initiating bleeding and
sealing with MTA
 The final coronal restoration will depend on individual
need and be billed separately
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KEY REVISIONS FOR 2011/2012
Revise Nomenclature and Descriptor
 D7960 — Frenulectomy — also known as
frenectomy or frenotomy — separate procedure not
incidental to another separate procedure
Surgical removal or release of mucosal and muscle
elements of a buccal, labial or lingual frenum that is
associated with a pathological condition, or
interferes with proper oral development or
treatment.
FRENOTOMIES/FRENULOPLASTIES
When appropriate to bill
Medical or Dental Insurance?
 Medical
 CPT codes have global period which includes
 Local anesthesia
 One related evaluation and management E/M
encounter immediately prior to decision for surgery or
on day of surgery
 Immediate post- operative care
 Writing orders
 Evaluating patient in recovery room
 Routine post operative follow-up care
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FRENOTOMIES/FRENULOPLASTIES
When appropriate to bill
Medical or Dental Insurance?
 Medical – Labial Frenotomy
 CPT 40806 incision of labial frenum – frenectomy
 Applicable ICD-9 diagnosis codes
 524.71 Alveolar maxillary hyperplasia
 524.72 Alveolar mandibular hyperplasia
 525.20 Unspecified atrophy of edentulous alveolar
ridge
 528.79 Other disturbances or oral epithelium
 756.82 Other specified anomaly of muscle, tendon,
fascia, connective tissue and accessory muscle
 0 day global package (all associated visits are billable)
FRENOTOMIES/FRENULOPLASTIES
When appropriate to bill
Medical or Dental Insurance?
 Medical – Ankyloglossial/tongue tie
 CPT 41010 incision of lingual frenum
 ICD-9 diagnosis code
 750.0 tongue tie
 524.02 Mandibular hyperplasia
 524.74 Alveolar mandibular hypoplasia
 750.12 Congenital adhesions of tongue
 0 day global package (all associated visits are billable)
 OR dentist may perform
35
FRENOTOMIES/FRENULOPLASTIES
When appropriate to bill
Medical or Dental Insurance?
 Medical
 Zplasty (4 incisions vs 1 incision)
 CPT 41520 – frenuloplasty-surgical revision of frenum
 90 day global period (routine post operative visits and
office visit and exam on day of procedure cannot be
billed separately to patient or carrier)
FRENOTOMIES/FRENULOPLASTIES
When appropriate to bill
Medical or Dental Insurance?
 Continued
 ICD-9 codes that support necessity for CPT 41520 may
include
 524.04 Mandibular hypoplasia
 529.8 Other specified conditions of the tongue
 750.0 Tongue tie or ankyloglossia
 750.10 Anomaly of tongue, unspecified
 750.12 Congenital adhesions of tongue
36
FRENOTOMIES/FRENULOPLASTIES
When appropriate to bill
Medical or Dental Insurance?
 Dental
 Labial Frenotomy
CDT code D7960 — frenulectomy
 Ankyloglossial/tongue tie
CDT code D7960 — frenulectomy
FRENOTOMIES/FRENULOPLASTIES
When appropriate to bill
Medical or Dental Insurance?
 Determine medical necessity
 Understand coverage guidelines of patient’s medical policy
 Base each decision individually
37
KEY REVISIONS FOR 2011/2012
Revised Nomenclature D9215
 D9215 local anesthesia — local anesthesia in
conjunction with operative or surgical
procedures
(Use when a procedure has been started but
unable to complete)
KEY REVISIONS FOR 2011/2012
Revise Nomenclature and Descriptor
 D9420 hospital or ambulatory surgical center call
May be reported when providing treatment care provided
outside the dentist’s office to a patient who is in a hospital
or ambulatory surgical center. Services delivered to the
patient on the date of service are documented separately
using the applicable procedure codes in addition to reporting
appropriate code numbers for actual services performed.
38
KEY REVISIONS FOR 2009/2010
Changes in 2009/2010 cycle, a New Code was
adopted
 D3222 — Partial Pulpotomy for Apexogenesis —
permanent tooth with incomplete root
development
 Removal of a portion of the pulp and
application of a medicament with the aim of
maintaining vitality of the remaining portion to
encourage continued physiological
development and formation of the root. This
procedure is not to be construed as the first
stage of root canal therapy.
Apexogenesis – D3222
Immature permanent tooth
with pulp exposure due
to caries or trauma
Only remove the infected
part of the pulp from the pulp
chamber (partial pulpotomy)
Goal =
develop
a root
end (apex)
to avoid
apexification
39
Pulpotomy D3220 (Primary)
Primary tooth with
caries into the pulp
Goal:
To retain tooth
vitality until
tooth
exfoliates
Remove all pulp
from the pulp
chamber
Pulpotomy D3220 (Permanent)
Permanent tooth with
caries into the pulp
Goal:
To buy time
until patient
is able to proceed
with RCT
Remove all pulp
from the pulp
chamber
40
Apexification–D3351-D3353
Permanent tooth root will never mature due to
caries or trauma
Goal:
To save
the tooth
Develop a
calcified barrier
at root end and
complete root
canal
KEY REVISIONS FOR 2009/2010
 D9220 — Deep sedation/general anesthesia —
first 30 minutes
 D9221 — Deep sedation/general anesthesia —
each additional 15 minutes
 The level of anesthesia is determined by the
anesthesia provider’s documentation of the
anesthetic’s effects upon the central nervous
system and not dependent upon the route of
administration.
41
KEY REVISIONS FOR 2009/2010
 D9241 — Intravenous conscious
sedation/analgesia - first 30 minutes
 D9242 — Intravenous conscious
sedation/analgesia — each additional 15 minutes
The level of anesthesia is determined by the
anesthesia provider’s documentation of the
anesthetic’s effects upon the central nervous
system and not dependent upon the route of
administration.
KEY REVISIONS FOR 2009/2010
 D9248 — Non-intravenous conscious sedation
 The level of anesthesia is determined by the
anesthesia provider’s documentation of the
anesthetic’s effects upon the central nervous
system and not dependent upon the route of
administration.
42
The Future of the Insurance
Industry
Insurance Paradigm Shift
“The nation’s largest dental carriers (Aetna, BCBS, CIGNA, Delta, MetLife,
etc.) have been tracking their internal data for years. The preponderance
of evidence suggests that it makes more economical sense to the patient,
insurance carrier, and the employer purchasing the plan to pay for
prevention rather than paying for the restoration or extraction of teeth.
As a result, some of the nation’s largest dental plans are covering more
preventive and diagnostic services in hopes of avoiding more costly and
invasive restorative services in the future”.
Richard Celko
Aetna’s National Dental Director of Utilization Management
43
Insurance Paradigm Shift
 Evidenced Based Dentistry
 Disease Risk Assessment
 Caries
 Periodontal Disease
 Focus on preventive over restorative
 Review and reimburse based on treatment
success vs. failure rate
Insurance Paradigm Shift
 Dollars spent on those with greatest needs based
on risk assessment
 This will effect:
 the number of cleanings/year
 frequency of fluoride treatment
 Potential for changes in reimbursement of
treatment provided
44
Cost Benefits of Preventive
Dentistry
 Dental disease is one of the leading causes of
school absenteeism for children:
 Children miss 51 million hours of school due to
dental problems.
 Workers lose 164 million work hours because
of dental disease.
 According to the Journal of Dental Education,
oral-related illnesses account nationally for 3.6
million days of bed disability, 11.8 million days
of restricted activity and 1 million lost school
days.
Cost Benefits of Preventive
Dentistry
 The cost of providing preventive dental treatment is
estimated to be 10 times less costly than managing
symptoms of dental disease in a hospital emergency
room.
 Preventive care and early detection and treatment
save $4 billion annually in the United States. (Delta
Dental)
 Children who receive preventive dental care early
in life have lifetime dental costs that are 40
percent lower than children who do not receive
this care.
45
Cost Benefits of Preventive
Dentistry
 Every American should receive the care necessary
to promote good oral health.
 Most dental diseases are preventable, and early
dental treatment has proven to be cost effective.
Guideline on Caries Risk
Assessment and
Management
 The current CAT policy was revamped into a Guideline
that:
 Is more comprehensive and
 will include risk assessment and management pathways
 The AAPD Board approved at 2010 Annual Session
 Pediatric Dentistry Reference Manual
 www.aapd.org
46
Guideline on Caries Risk
Assessment and
Management
 This new guideline recommends more specific
interventions for children based upon their:
 ages
 parental engagement, and
 assessed caries risk
Guideline on Caries Risk
Assessment and
Management
 Previously, the policy on risk assessment had a single
assessment chart for use across all ages. Now we break
down our assessment forms for dental vs non-dental
healthcare providers;
 for dental professionals, we analyze risk for
different age ranges.
 We added recommendations for care based upon
these previously mentioned factors. These
recommendations are based upon the best current
scientific evidence we have available.
47
Guideline on Caries Risk
Assessment and
Management
 Hygienists – take note
 New guideline promotes sealants in teeth with
deep fissure anatomy or developmental defects
in 3-5 year olds.
 No longer wait for 6 year molars before we think
about sealants
 And for motivated families, we‘ve added xylitol
into the preventive program for some kids
Caries Management
Protocol
 Guideline Includes Tables For:
 Caries management protocol for 1-2 year olds
 Caries management protocol for 3-5 year olds
 Caries management protocol for > 6 year olds
48
Risk Factors Influence
 How aggressive we treatment plan
 Restoration choice, materials used
 Fluoride usage
 Setting
 Frequency of radiographs
 How we code
 How claims are adjudicated
Documentation is critical
Documentation
 Key to justify treatment provided
 Radiographs
 Clinical Notes and charting
 Photographs, etc
 Medical Legal requirements
 Utilization reviews - profiling
49
How often do you take BWX
 Frequency depends on patient’s needs
 Caries Risk and History
 Should not be dictated by patient’s benefits
 Must document risk factors to justify if frequency
falls outside of FDA guidelines
Occlusal films
 D0240 is reported based on projection
technique; not the size of the film
 Carriers sometime deny coverage based on size
of film for occlusal films. This is not appropriate.
50
ADA/FDA Radiographic
Guidelines
 Recommendations for bitewing intervals vary
depending on:
 Patient’s age
 Risk for caries
 Periodontal disease
 Dentofacial growth and development
 Restorative and endodontic needs
 Caries remineralization
Caries Remineralization
D1206 — topical fluoride varnish: therapeutic
application for patients with moderate to high
caries risk
 Not to be used for desensitization
 Patient has moderate to high caries risk if one or
more factors apply
51
Fluoride Varnish
 It is concentrated: 5% NaF in a resin base.
 It can be used as a topical fluoride, especially in precooperative youngsters.
 When used in this fashion on children with low caries
risk, D1203 applies. If you use Fl varnish across the
board, must bill D1203 for low caries risk
 It can be used to retard, arrest and reverse the caries
process in children with moderate to high caries risk.
 When used in this fashion, D1206 applies.
 Application frequency as often as quarterly.
Why was Fluoride Varnish
Applied?

D1203/D1204

Preventive protocols

Low caries risk patients

D1206

Therapeutic

Moderate to high caries risk patients

D9910

Desensitization
 Root sensitivity
 Thermal sensitivity
52
New Product
ICON
 New composite product ICON by DMG America that
penetrates the dentin. Carriers are not covering this
technique currently.
 Patients should be informed that they must pay out of
pocket for this in advance.
 DMG has put forth a proposals for a new codes for both
applications in CDT 2013
 resin infiltration of facial non-cavitated lesion
 resin infiltration of proximal incipient lesions
New Product
Pre-fab milled zirconium
crown-primary
 AAPD put forth a request for a new code (CDT-2013) for
D29XX — prefabricated porcelain/ceramic crown — primary
tooth
A pre-fabricated, individually-milled zirconium crown for both
anterior and posterior primary teeth has been introduced
into the marketplace and into clinical practice.
53
The Dental Home
 A professional environment where a child’s oral
health care is delivered in a comprehensive,
continuously accessible, coordinated and familycentered way by a licensed dentist.
The Age One Visit
 The AAPD recommends the child’s first visit to be
no later than age one, but preferably within six
months of the first tooth’s eruption.
 By visiting the dentist at that time, a Dental Home
can be established and Anticipatory Guidance be
made part of the child’s total health care
experience.
54
The Infant Oral Exam
(D0145)
DO145 — Oral evaluation for a patient under three years of
age and counseling with a primary caregiver
Diagnostic services performed for a child under the age of
three, preferably within the first six months of the
eruption of the first primary tooth, including the recording
the oral and physical health history, evaluation of caries
susceptibility, development of an appropriate preventive
oral health regimen and communication with and
counseling of the child’s parent, legal guardian and/or
primary caregiver.
D0145: The responsibility of
the industry
 It is incumbent upon third party administrators
and vendors to:
 Educate their product purchasers as to the
reasons for the inclusion of D0145 into the
CDT.
 Encourage purchasers and decision makers to
include this procedure into the chosen
benefit package
 Avoid down-coding or establishing lower
remuneration
55
D0145
Appropriate Reporting
 May report this as often as necessary before age
three
 Compliant patients may “advance” to the D0120
 Non-compliant patients may need repeated
education, counseling and encouragement. This
is the D0145!
Strip Crowns
 Code as a restoration…not as a crown
 Typically it is coded as
 D2335 — resin-based composite — four or
more surfaces or involving the incisal angle
(anterior)
 D2394 — resin-based composite — four or
more surfaces,posterior
56
Aesthetic Stainless Steel
Crowns
 Pediatric dentists should have choice/ freedom to
use what type of crown is most appropriate for
patient based on risk factors, age, etc.
 D2933 pre fab esthetic SSC w/ resin window
 D2934 pre fab esthetic SSC
 D2335 composite strip crowns
Space maintainers
 Some carriers will cover unilateral space
maintainers but not bilateral space maintainers –
force dentists to bill unilateral twice.
 AAPD discussed this with the carriers at the
Insurance Summit in May
57
Medical Billing Resource
 Instructions on medical billing and
documentation included in the AAPD Coding and
Insurance Manual
 Effective January 1, 2011 to December 31, 2012
Common Medical Billing
Situations for Pediatric
Dentistry
 Trauma related dental procedures
 Biopsies and excisions
 Surgical excisions
 TMJ conditions
 Restorations due to GERD, bulimia, saliva-inhibiting
medications
58
Administrative Challenges
Administrative Challenges
 Appealing denied claims
 Prompt payment laws
 Overpayment refund requests
 Fees
 Coordination of benefits
59
Fully Insured Dental Plans
 Traditional insurance
 Carrier is at risk for payment of claims
 Dental plan is regulated by the Department of
Insurance in the state where it is licensed/sold
Self-Funded Dental Plans
 Also called Administrative Services Only or Administrative
Services Contract
 Trend – this is majority of plans today
 Employer bears the entire risk of utilization
 Third Party administrators provide claims processing and
other administrative services without bearing risk of
utilization
 Regulated by Employee Retirement Income Security Act of
1974 (ERISA), not the State Department of Insurance
 Does not need to abide by State Insurance Regulations
60
Writing Narratives
 What did the dentist see that made him/her
decide what treatment was necessary and
appropriate?
 Is the information obvious on the x-ray?
 If not obvious to claim reviewer, send a narrative
stating what cannot be seen on the x-ray
 Clearly document in your charts
Appealing Denied Claims
Service not covered
By patient’s plan
Plan’s payment criteria
not met
Send a copy of
denied EOB
Direct patient to
Employer Benefits Manager
Write “requesting
2nd review”
Provide narrative
with add’l info
Attach x-ray,
Photos, chart notes
61
Prompt Payment
Requirements
 Regulated by state insurance laws?
 Prompt payment laws only apply to fully insured plans
licensed in the state where the plan is sold
 PPO contract require prompt payment?
 Provider contract may define carrier’s prompt payment
obligation and interest penalty
 ERISA/ US Department of Labor
 Self-insured dental plans are regulated by the Employee
Retirement Income Security Act of 1974
 ERISA only requires acknowledgement that claim was
received within 45 days
ERISA Prompt Payment
Requirements
 Q. Does ERISA require dental claims to be paid within a
certain number of days?
 A. “There is no requirement for claims to be paid within a
certain number of days under ERISA.”
Lesley Radcliff,
US Dept. of Labor
62
Prompt Payment Requirements
Fully Insured Plan
State Dept. of Ins
Prompt Payment
Law
Suggest patient
complain to
State Ins. Commissioner
Self-funded Plans
No Provider
Contract
Provider
Contract
ERISA –
Notice of Receipt
within 45 days
Refer to Contract
For Plan’s
Timely Payment
Obligation
Suggest patient
complain to employer
Complain to
network rep
Refund Requests
 Is the dental plan regulated by state insurance
laws?
 States often have “Right of Recovery” laws
 This only applies to plans licensed in state
 Statutory time limitations vary state to state
 Workers Comp and Medicaid refunds are
regulated by state statute
63
Refund Requests
 Does your PPO contract address refunds?
 Provider contracts often define the provider’s
responsibilities to refund overpayments
ERISA Refund Requirements
 Q. Does ERISA define when a dental plan can
require a refund if a payment was made in
error?
 A. “There are no set guidelines for when a
dental plan can require a refund. If the
error is not corrected, then the matter must
go through the court system.” Lesley Radcliff, US Dept.
of Labor
64
Insurance Refund Requests
Fully Insured Plan,
Medicaid or
Workers Comp.
State Statute or Dept. of
Insurance
Right of Recovery
Law
Check timeframe and
consider sending
appeal letter
Self-funded Plans
No Provider
Contract
Don’t send check
Send appeal letter
Courts must decide
Provider
Contract
Refer to provider’s
contract for
refund obligation
Negotiating PPO Fees
 Don’t assume that carriers will regularly increase
your PPO fees
 Write a letter or contact your network
representative annually to negotiate fees. If the
network is robust, chances are slim that carrier
will negotiate. Know the # of providers in your
local network.
 Target 10 procedures you want fee increased
 Know what UCR percentile you have agreed to
accept
65
Common Coding Questions
 When is it appropriate to bill D9310?
 If a patient has been referred to you for
evaluation by another dentist.
 What evaluation code should I bill when a patient
presents without a referral and the comprehensive
evaluation has already been used by another
dentist?
 Any of the evaluation codes that best match
your treatment…typically for a specialist, D0140
is best.
Common Coding Questions
 Is there a dental code for "alternative restorative treatment"
(ART)?
 The revised code D2940 in 2011 for a protective restoration
 Direct placement of a temporary restoration intended
restorative material to protect tooth and/or tissue form.
This procedure may be used to relieve pain, promote
healing, or prevent further deterioration. Not to be used
for endodontic access closure, or as a base or liner under
restoration.
 The AAPD's oral health policy on Interim Restorative
Treatment can be accessed at:
http://www.aapd.org/media/Policies_Guidelines/P_ITR.pdf
66
Common Coding Questions
 What Code should be used to report an evaluation on
a very young child?
Code D0145 — oral evaluation for a patient under
three years of age and counseling with primary
caregiver
Common Coding Questions
 How do I report a supernumerary tooth?
 Permanent teeth: Add +50 to the nearest tooth number
 The supernumerary near tooth 14 is identified as #64
(see page 90 of the AAPD Coding Manual)
 Primary teeth: Add “S” to the nearest tooth number
 The supernumerary near tooth “C” is identified as “CS”
(see page 90 of the AAPD Coding Manual)
67
Common Coding Questions
What age is considered a child versus an adult?
According to the ADA Resolutions, the age of a “child”
Resolved, that when dental plans differentiate coverage based on the
child or adult status of the patient, this determination be based on
clinical development of the patient’s dentition, and be it further
Resolved, that where administrative constraints of a dental plan
preclude the use of clinical development so that chronological age
must be used to determine child or adult status, the plan defines a
patient as an adult beginning at age 12 with the exclusion of
treatment for orthodontics and sealants.
Space maintainers
 Report the anchor tooth/teeth
 Include narrative to report that space(s) that are
being maintained
68
Record Keeping and
Documentation








Understand importance for complete records
Identify a comprehensive medical/dental history
Accurately chart an initial examination
Diagnose and sequence treatment plans
Determine what adequate radiographs are
Understand role of informed consent
Identify a record and who “owns”it
Become familiar with common coding errors
Questions?
69