Dental insurance rarely covers 100% of the dental fees; some services are reimbursable and some are not. It is important for dental practices to understand the services that can be billed. Dental insurance plans vary in the kind of procedures they cover; these may also vary from state to state.
The CDT (Current Dental Terminology) Manual lists the codes for various dental procedures, which have to be used on the claim form. This manual is published by the American Dental Association (ADA) every two years. Dental practices and offices have to use the current code terminology to prevent delayed reimbursements and claim denials.
Dentistry codes fall into 12 service categories:
- Diagnostic D0100-D0999
- Preventive D1000-D1999
- Restorative D2000-D2999
- Endodontics D3000-D3999
- Periodontics D4000-D4999
- Prosthodontics, removable D5000-D5899
- Maxillofacial Prosthetics D5900-D5999
- Implant Services D6000-D6199
- Prosthodontics, fixed D6200-D6999
- Oral and Maxillofacial Surgery D7000-D7999
- Orthodontics D8000-D8999
- Adjunctive General Services D9000-D9999
Dental Procedure Code – Components
A dental procedure code comprises:
- A 5 character alpha numeric code as the ones listed above
- Nomenclature or a written definition of the dental procedure code
- Descriptor or an elaboration to clarify the intended use of the dental procedure code
It is important to understand that just because a dental procedure code exists, it doesn’t mean that it is reimbursable under a dental benefits plan.
Medical Claims for Dental Procedures
Dentistry is now being recognized as the field of dental medicine with advanced research in the field proving that oral conditions can have an impact on body systems and vice versa. Dentistry medical coding is becoming more important now with insurance carriers recognizing the connection between medical and dental procedures.
Some dental claims may be filed with or may be covered by medical benefit plans. These are different from claims covered by dental benefit plans. Dental practices can submit medical claims for dental procedures that are considered medically necessary. A clear understanding regarding medical necessity of dental procedures provided for patients is vital in this scenario. It is to be expected that dental practices will have to report diagnosis codes for all procedures in the near future. Experienced medical coders can help dental practices correctly bill for the services provided and thereby receive maximum reimbursement.
Dental procedures that can be billed include:
- Oral surgical procedures
- Implant procedures considered medically necessary
- Periodontal procedures that are medically necessary
- Laser procedures considered medically necessary
- Consultations and examinations for orofacial medical conditions
- TMD procedures
- Procedures associated with oral dysfunction
- Dental procedures related to trauma
- Screenings for oral cancer
- Dental procedures for myofascial pain conditions
- Sleep apnea procedures
- X-rays, including CT scans considered medically necessary and associated with the procedures above
What is Dental/Medical Cross Coding?
The coding systems are different as regards a dental claim and a medical claim. Insurance providers for dental procedures ask only for a procedure code, whereas medical insurance carriers ask for a diagnostic code also-it has to be made clear why a particular procedure was done. To get maximum reimbursement for dental procedures, dental practices need to recognize the importance of accurate dental-medical cross coding. You will have to be very clear about the medical necessity of a particular dental procedure.
Dental practitioners report their procedures using CDT codes, whereas medical procedures are reported using the CPT code set. Many medically necessary dental procedures can be reported using CPT codes, but you need to have thorough knowledge regarding these. If there is a CPT code that describes the dental procedure, it has to be provided in the claim form.
CDT codes for dental procedures fall under the Level II CPT code, namely, the HCPCS codes. So, when the CPT code for a particular procedure is not very clear, dentists can report the procedure using CDT codes, provided the medical carrier accepts HCPCS codes. Medical claims also require an ICD-9-CM diagnosis code. Conditions that are described by the terms ‘suspected,’ ‘probable,’ ‘rule out’ or ‘questionable’ cannot be reported on a medical claim. Codes that can best describe the patient’s actual diagnosis only can be used.
Medical coders for dentistry should be well-versed in:
- Dental medical cross coding
- Dental procedures that fall under the ‘medically necessary’ category
- Dental insurance and medical insurance coding systems
- Using proper medical codes and forms
Insurance trends are always changing, and medical coders and dentistry practices have to keep themselves updated regarding these.
Diagnostic Codes for Dentistry – SNODENT (Systematic Nomenclature of Dentistry)
This code set is being developed to represent dental diagnoses. It is expected to contain ‘codes for identifying not only diseases and diagnoses but also anatomy, conditions, morphology, and social factors that may affect health or treatment.’ This new coding system is expected to facilitate coding of not only dental conditions, but also concurrent medical conditions and risk behaviors (such as diabetes, smoking) that might affect the patient’s overall health and have an important consideration when prescribing treatment.