CDT 2015 Coding Options. Codes and Coverage. Option to Help Support Dental/Medical Necessity for Care

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1 Codes and Coverage This document is about coding. Coding and coverage are NOT the same. The existence of a code does not mean a patient has coverage under a policy. Yet without a code, no coverage could be offered. This is where confusion lies. Codes and coverage are related but not the same. Using the most accurate code and coding for all procedures is important for future structured data in electronic health records. It can also serve today as the most accurate documentation and possible coverage under a policy. Dental professionals are obligated to use the most accurate code available. Accurate coding does guarantee coverage under a particular policy. CDT codes are risk and diagnosis based, not product based. Before specific codes suggestions are made to facilitate best coverage under a policy including dental/medical necessity data in Box 35 Remarks is important. Option to Help Support Dental/Medical Necessity for Care Codes were added for Caries risk. There may/may not be coverage for these codes but should be submitted in conjunction with other codes. Risk assessment will help determine diagnosis. These can be considered modifier codes that support WHY for other care. D0601 caries risk assessment and documentation, with a finding of low risk D0602 caries risk assessment and documentation, with a finding of moderate risk D0603 caries risk assessment and documentation, with a finding of high risk Description for all 3 codes: Using recognized assessment tools. Because the code contains the word documentation, writing the dental/medical necessity in this case the method of determining caries risk is needed. A wide variety of quantifiable caries risk assessment tools are available: Paper/computer based Q&A o o o o (open access to 60 million Delta Dental participants) Saliva tests Bacterial tests Luminescence technologies

2 Profluorid Varnish 2015 Update: D1208 topical fluoride code words add excluding varnish. Previously fluoride varnish could be submitted under either D1208 or D1206; this change no longer gives the practice a choice. D1206 topical application of fluoride varnish. All age based information has been removed from codes several years ago. Policies may differ. To optimize coverage, document dental medical necessity in Box 35 Remarks. xx/xx/2015 D0602 caries risk assessment and documentation, with a finding of high risk xx/xx/2015 D1206 Topical application of fluoride varnish High risk per ADA risk assessment, restoration 2/11/15. (Note: on most RA systems, a single restoration in 3 years = high risk) Remin Pro Does not qualify under fluoride codes based on D100 D1999 Preventive section general description: (From CDT 2015) Prescription strength fluoride product designed solely for use in the dental office, delivered to the dentition under the direct supervision of a dental professional. Option 1: D9910 application of desensitizing medicament: Includes in office treatment for root sensitivity. Best option is the patient chief complaint (dental/medical necessity) is sensitivity. xx/xx/ D9910 application of desensitizing medicament Thermal sensitivity generalized

3 Option 2: D9630 other drugs and/or medicaments by report.* Includes, but is not limited to oral antibiotics, oral analgesics, and topical fluoride dispensed in the office for home use; does not include writing prescriptions. By Report means, this code requires a narrative Box 35. xx/xx/ D9630 Other drugs/medicaments by report Cancer radiation therapy, sensitivity, and extreme oral dryness Option 3: D1999 unspecified preventive procedure, by report* Every other section in CDT had a D_999 code for unspecified procedures except Preventive. *as noted above By Report codes require a narrative. May NOT the best option but does qualify under code description. xx/xx/ D1999 Unspecified preventive procedure, by report Early Childhood Caries care preventive product

4 Profluorid L Due to unique nature of this liquid resin based product, a couple of options are available. Option 1: D2990 resin infiltration of incipient smooth surface lesions. Description: Placement of an infiltrating resin restoration for stabilizing and/or limiting the progression of the lesion. See narrative for dental medical necessity. xx/xx/2015 D0602 caries risk assessment and documentation, with a finding of high risk xx/xx/2015 D2990 resin infiltration of incipient smooth surface lesions High risk per diagnostic images showing incipient caries see attached image Option 2: D9910 application of desensitizing medicament. Description: Includes in office treatment for root sensitivity. Typically reported on a per visit basis for application of topical fluoride. This code is not be used for bases, liners or adhesives used under restorations. xx/xx/ D9910 application of desensitizing medicament Cancer radiation therapy, generalized sensitivity, and extreme oral dryness

5 Grandio Seal and Control Seal To again emphasize Codes are NOT product based. These sealants products have similar AND different properties. The selection for use is dependent on the risk assessment and diagnosis and is the difference there might in coding. Option1: D1351 sealant per tooth. Description: Mechanically and/or chemically prepared enamel surface sealed to prevent decay. Option2: D2940 protective restoration: Direct placement of a restorative material to protect tooth and/or tissue form. This procedure may be used to relieve pain, promote healing, or prevent further deterioration. The most accurate coding is based on the risk assessment and diagnosis. Consistently documenting Caries Risk Assessment Codes and diagnosis which is the medical dental necessity will help best facilitate submission. See previous examples. Admira Protect Nano filled desensitizing product Option 1: D9911 application of desensitizing resin for cervical and/or root surface, per tooth. Description: Typically reported on a per tooth basis for application of adhesive resins. This code is not be used for bases, liners or adhesives used under restorations. xx/xx/ D9911 application of desensitizing resin for cervical and/or root surface, per tooth Extreme thermal sensitivity

6 D1999 unspecified preventive procedure, by report. Every procedure has a code. If no other code fits, CDT has a D_999 code for unspecified procedures. Note: By Report codes requires a narrative. xx/xx/ D1999 Unspecified preventive procedure, by report Early Childhood Caries care preventive product FREE Bonus gift: CDT 2015 Shifts ebook an update for the codes starting on 1/1/15. It can be read on your smart phone, tablet or any computer. Here is how to download: 1. Go to 2. On the bottom of the screen, put in the code YR324LKD (case sensitive) 3. Scroll to the top of the screen and click download. Disclaimer: The presence of a CDT Code does not mean that the procedure is endorsed by any entity or is considered a standard of care or that is it covered or reimbursed by a dental benefits plan. Current Dental Terminology (CDT) and SNODENT 2015, copyright 2015 American Dental Association (ADA) and used by permission. All rights reserved. The author, Patti DiGangi, RDH, BS, an ADA CDT licensee specifically assumes no liability, responsibility, or guarantee whatsoever for specific adjudication of a claim, survival of an audit by insurance company or government entity, and acceptability of a narrative or any code reported. The author has attempted to verify the information herein, but assumes no responsibility for omissions, inaccuracies, or errors. This information is educational and not intended to be legal advice.