As dentists focus their time and energy on treatment, they need to pay attention to the revenue side of their practice. One common concern for many dental practices is about assigning codes to report various procedures for reimbursement purposes. In fact, many practices rely on outsourced dental billing services to manage this. Success with dental billing depends to a great extent on having a proper understanding of the various code sets – CDT, CPT and ICD – and when to use them. Each code set has a different purpose and each payer has their own rules for claim submission using these codes.
CDT Dental Codes
The CDT code set maintained by the American Dental Association consists of procedural codes for oral health and adjunctive services provided in dentistry. Each alphanumeric CDT code begins with the letter ‘D’ (the procedure code) and is followed by 4 numbers (the nomenclature). CDT codes are used by dentists to report dental procedures in claims to insurance companies. CDT codes also help dentists achieve uniformity, consistency and specificity in documenting dental treatment accurately in the electronic health record. CDT codes are updated and revised annually.
The CDT Code set categorizes codes by type of service: diagnostic, preventive, restorative, endodontics, periodontics, removable prosthodontics, maxillofacial prosthetics, implant services, fixed prosthodontics, oral and maxillofacial surgery, orthodontics, and adjunctive general services. However, nothing in the CDT supports or indicates limitation of use by dentists – general dentists or specialists – to any categorical section(s) of the CDT Code.
The CPT code set is maintained by the American Medical Association and used to report medical procedures and services to payers. CPT codes are often referred to as Level I codes.
ICD-10 codes are diagnostic codes used to group and identify diseases, disorders and symptoms. Each diagnosis code is a unique, alphanumeric string of characters representing a disorder or disease concept. Diagnostic coding involves transforming verbal descriptors of diseases, illnesses and injuries into standardized codes in claims for services.
Code Use in Dental Practices – Key Considerations
Use CDT codes to bill dental services: When to use CDT or CPT codes would depend on the type of insurance to which the claim is submitted matters. CDT is designated a HIPAA standard code set. All claims submitted on a HIPAA standard electronic dental claim must use dental procedure codes from the CDT code version in effect on the date of service. Both in-network and out-of-network providers should use CDT codes for billing dental services on claims to third-party payers.
Consider type of coverage – dental or medical: A major factor governing CDT vs. CPT code use is the type of coverage that the patient has. To assign a CDT dental code on the claim for a dental procedure, the patient must have dental insurance. However, based on the patient’s insurance policy coverage, medical insurance can be billed if the patient received dental care related to a medical condition. As medical plans do not pay for treatment claimed as CDT procedures, dentists need to report the correct CPT codes to describe the medical treatment when submitting claims to medical plans (www.cda.org). Examples of dental procedures that can be billed to medical insurance include:
- All oral and dental procedures associated with any kind of traumatic injury to the mouth
- Exams and consultations when oral cancer screening is done, and in preparation for any other medically billable procedure
- Emergency treatment of oral inflammation and oral infections
- Diagnostic, radiographic, and surgical or healing stents
- Radiographs for certain screening and diagnostic purposes
- Biopsies and excisions, including smears and brush biopsies
- Surgery associated with interim and final prostheses necessitated by a traumatic injury or any medical condition
However, to bill medical insurance, the dental code intended to be used should have a compatible medical code. This can be identified by cross referencing with the CPT book. Examples of procedures that have a compatible CPT code are:
- Alveoloplasty w/ extractions per quadrant D7310 / 41874
- I & D of abscess – intraoral soft tissue D7510 / 41800
The standard practice is to submit the dental claim first and then, if it is denied, submit a medical claim.
Coming to diagnostic codes, ICD codes may be used along with CDT codes on claims submitted to dental benefit plans when needed but are always required on claims for dental services submitted to medical benefit plans. ICD-10 codes in claims filed for dental benefits inform the payer why the procedure was performed and the associated disease, illness, symptom or disorder. The ICD-10 code categories K00 to K95 which describe diseases of the digestive system include diseases of the mouth and conditions treated by dentists. The appropriate diagnosis code should be selected based on the patient’s present condition(s).
Using the correct codes and ensuring proper clinical documentation is essential for timely and appropriate reimbursement as well as to avoid charges of fraud or violations of state or federal law, including noncompliance. Adding to the complexity is the fact that every payer/insurance carrier has their own rules regarding coverage of certain dental expenses. Other areas of concern in dental practices include appeals processes, understanding an EOB, credentialing with medical carriers, and dental insurance verification. The good news is that outsourcing dental billing to an expert can go a long way in ensuring correct code use and efficient claim submission.