Dental Procedure Codes

1. Dental Procedure Codes The Good, The Bad, and The Ugly

2. Communication “The language of reimbursement?” Dental Procedure Codes!

3. Fee-for-service • Third Party Payers • Government Programs

4. 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

5. 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.

6. 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

7. 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)

8. 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

9. 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

10. Categories of Service 10

11. 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.

12. 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.

13. How are dental procedure codes changed? • In 2000, a code revision committee was established to update the code bi-annually. • 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.

14. 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

15. 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

16. 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.

18. 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.

19. 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?

20. 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.

21. Changes effective – 01/01/2013 161 code change requests submitted for consideration 35 Additions in 8 categories 37 Revisions in 9 categories 12 Deletionsin 4 categories 21

22. 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

23. What’s on the horizon? • Codes for procedures using lasers (???) • Expanding current codes to allow use of new materials (e.g. GINTUIT, etc) • ????????????????????????????????

24. 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

25. Code Maintenance Committee ADA Standards Committee on Dental Informatics SNODENT ICD-9 and ICD 10 Dental Quality Alliance

26. 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

27. 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

28. SNODENT • Has input for periodontal diagnostic codes developed by the ADA • Monitors updates and changes

29. ICD-9 and ICD-10HCPCS • Monitors updates and changes for medical diagnostic (ICD-9) and procedure codes (HCPCS) applicable to periodontics.

30. ADA claim form – Diagnosis Codes Diagnosis Code Pointer ICD-9-CM Diagnosis Code (at least one) 30

31. Dental Quality Alliance Voting member of alliance to develop quality measurements for the dental profession

32. Educational Opportunities Annual Meeting Insurance Workshops: Dental and medical coding for reimbursement State and Regional Insurance Workshops

33. 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.

35. 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

36. 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

37. 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.

38. So how does this fit into residency programs?

39. Beginning a practice or joining a group practice can be overwhelming: Fee-for-service vs contractual plans Participant vs Non-participant Contract analysis

40. 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

41. Best Practices for the Periodontist Ethical Guidelines for care Legal responsibilities

42. 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?

43. 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?

44. We are a wealth of information!