Dental Coding: The Who, What, When and How of Dental Codes

September 2019 | Article

By Susan Rohde

A key area of concern for many dental practices circles around dental codes and their ability to properly code various procedures for insurance purposes. Using the correct dental code is critical, and often confusing.

While medical coding relies on Current Procedural Terminology (CPT), dental coding utilizes Current Dental Terminology (CDT). The CDT, maintained by the American Dental Association (ADA), contains all the dental codes required to code each dental procedure(s) for submission to dental insurance plans.

What is the CDT?
The CDT dental code is a set of procedural codes for oral health and dentistry. Each procedural code is an alphanumeric code beginning with the letter “D” (the procedure code) and followed by four numbers (the nomenclature). It also includes written descriptions for some of the procedural codes. The CDT Code set is categorized by types of service:

  1. Diagnostic
  2. Preventive
  3. Restorative
  4. Endodontics
  5. Periodontics
  6. Removable Prosthodontics
  7. Maxillofacial Prosthetics
  8. Implant Services
  9. Fixed Prosthodontics
  10. Oral and Maxillofacial Surgery
  11. Orthodontics
  12. Adjunctive General Services.

One major difference between CPT and CDT is nothing in the CDT supports or indicates the limitation of use of codes assigned by dentists—general dentists or specialists or hygienists—to any categorical section(s) of the CDT Code.

Do dental practices always use CDT Dental Codes?
Confusion often lies in questioning when to assign CPT codes and when to assign CDT codes. Typically, this is based on the type of insurance to which the claim will be billed.

Providers have three types of coverage options for billing:

  1. Medical
  2. Vision
  3. Dental

If you submit a dental benefit claims as either an in-network or out-of-network provider or engage in electronic communications or transactions that fall under HIPAA, you would use the CDT dental codes. The U.S. federal government has designated the CDT Code as the national terminology which must be used for reporting dental services on claims to third-party payers. The CDT was designated as the mandatory “standard” for electronic communication of dental services.

How do dental practices determine CDT dental codes?
To assign codes from the CDT, the patient must have dental insurance. If the patient does not have dental insurance, their coverage will not pay for any of the procedures performed. Many patients mistakenly believe their medical insurance also covers dental procedures.

It is important to pay attention to the type of coverage each patient has. If the patient does receive dental care that is “related” to a medical condition(s), medical insurance could be billed, dependent upon the specifics of the insurance policy coverage.

Example

If a patient has an abscess of the gums, which is incised and drained in the office, the procedure could be billed as either a dental procedure or a medical procedure. The dental (CDT) code for incision and drainage of abscess of the intraoral soft tissue is D7510, whereas the medical (CPT) code for the same procedure is 41800.

This means that the patient can go to either their dental or medical office to receive the same treatment, but different insurance companies would be billed.

While we understand that there is no black or white for assigning codes to medical versus dental plans, most medical plans contain stipulations that eliminate coverage for any treatment involving "teeth." Typical payor verbiage states that no payment will be made to either a physician or a dentist for services in connection with the care, treatment, filling, removal, or replacement of teeth. The exception is treatment because of acute accidental trauma to sound natural teeth or structures directly supporting the teeth. In addition, some medical plans will cover certain surgical procedures and/or TMJD issues and implants. Typically, the dental claim is submitted first; then, if it is denied, a medical claim is submitted.

How do dental practices submit using CDT dental codes?
While medical claims are submitted on their own claim form (CMS 1500 form); dental claims utilize the J400 form. This form is specifically designed to accommodate dental information. The following must be included on dental claim forms: 

  • Area of oral cavity
  • Tooth system
  • Tooth number or letter
  • Tooth surface
  • Description of procedure
  • Missing teeth information

This information is included when the dental hygienist or dentist performs the necessary procedures, and as such is indicated on the claim.

Proper medical coding can also be a safeguard against fraud. Learn more about other ways to prevent fraud in your dental practice.

2020 Updates to CDT Dental Codes
Each March, the ADA holds a maintenance committee meeting to determine new codes for the following year. For 2020, there were over 156 code change requests and of those, 37 new codes, 5 revised codes and 6 deleted codes will be added to CDT 2020 dental procedure codes. These will take effect on January 1, 2020.

A majority of the 2020 CDT changes relate to code specificity. Of special interest is a new code that applies to patients with special needs. This code will be assigned when “special treatment considerations for patients/individuals with physical, medical, developmental or cognitive conditions resulting in substantial functional limitations, which requires that modifications be made to delivery of treatment to provide comprehensive oral health care services.”

According to Delta Dental Plans Association, “currently there is no method for identifying dental services provided to patients with special needs. This nonclinical administrative code would facilitate the processing of claims and documentation of services directed at this high need population.”

A full list of code revisions will be published in October 2019 and will be available on the ADA website.

Why Correct Coding is Critical
Consistent, uniform, and accurate dental code assignment assists practices with proper record keeping and accurate insurance claim submissions. Accurate claims submission directly correlates to appropriate reimbursement for the dental services. A regular review of your coding can reduce the risk of fraud while providing assurance that claims are being filed compliantly. This is one step in keeping your dental practice running at its best.

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