Carol Tekavec, RDH
The latest revisions for the Current Dental Terminology codes have been completed by the ADA Code Revision Committee, made up of five ADA representatives and five "payer" (third-party) representatives. According to HIPAA regulations, all providers and payers will need to begin using these codes on January 1, 2005. Eighty-nine changes have been made, including 39 new codes, 47 revisions, and three deletions. (Visit my Web site at www.steppingstonestosuccess.com for information about my new coding handbook containing all CDT-2005 codes and insurance guidance.)
Among the changes are 11 new oral pathology laboratory codes, another revision to the D1110-Adult Prophy and D4910-Periodontal Maintenance descriptions, revised wording for topical fluoride treatment, and a new code for a transepithelial brush biopsy.
Local anesthesia is described as "usually considered to be part of" whatever procedure is being performed. Most carriers will not cover a separate fee for a local anesthetic in conjunction with treatment; however, a benefit may be provided if the anesthesia is used to aid in the diagnosis of a specific problem (D9210-Local Anesthesia not in Conjunction with Operative or Surgical Procedures). A narrative typically would be required.
D1110-Prophylaxis-Adult is defined as the "removal of plaque, calculus, and stains from the tooth structures in the permanent and transitional dentition. It is intended to control local irritational factors." This code is one of the most frequently revised codes in the CDT revision process. The CDT-4 description mentioned scaling to remove "coronal" plaque, calculus, and stains. The CDT-2005 version indicates that scaling is performed on "tooth structures," not just "coronal" portions of the tooth. It is thought that D1110 is intended to apply to any scaling and polishing procedures for adult patients. The patient may have gingivitis, but should not have any bone loss. Third-party payers commonly interpret D1110 as a "cleaning" for patients over age 13. Most carriers will continue to cover this service twice per year.
D4910-Periodontal Maintenance has a revised description specifying that implants, as well as the natural dentition, are included. No definitive mention is made of an exam and/or diagnosis performed by a dentist. However, it does stipulate that the intervals for the procedure are determined by the "clinical evaluation of the dentist." Therefore, it still appears that an exam may properly be coded separately. (The dentist's exam has not been listed in the definition since the CDT-1, 1990-1995.) Most carriers have begun to recognize a fee for a D4910 and a D0120-Periodic Oral Evaluation performed on the same date, but have reduced their payment amounts for a D4910 accordingly. D4910 and D0120 (or any other examination code) usually are covered only twice per year. More frequent procedures are typically the patient's responsibility.
D7288-Brush Biopsy-Transepithelial Sample Collection is a new code. It is believed that this code may be applied to the OralCDx brush biopsy. More dental payers are adding this procedure to their list of covered benefits. The ADA also is spotlighting the test as an important service dentists can provide. When part of a patient's plan, dental insurers are likely to cover the dentist's fee for the cell-sample collection. The lab fee claim can be filed directly by the lab and paid for by the patient's medical insurance. If suspicious cells are discovered with the brush biopsy, a scalpel biopsy (D7286) may be required at a later date. Carriers may cover both procedures if they are not listed on the same claim form on the same date.
The revised description of topical fluoride specifies "prescription-strength fluoride product designed solely for use in the dental office, delivered to the dentition under the direct supervision of a dental professional." This definition clarifies that "over-the-counter" fluoride products do not qualify. Benefits for fluoride treatments are frequently limited to twice per year for children through age 13 and for some adults with documented cervical caries.
Carol Tekavec, CDA, RDH, is the author of the Dental Insurance Coding Handbook Update CDT-2005. She is the designer of a dental chart and is a lecturer with the ADA Seminar Series. Contact her by phone at (800) 548-2164 or visit her Web site at www.steppingstonestosuccess.com.