So, what exactly did you find? The test is not payable as a benefit until you tell the insurance company what you found. This is the short and simple explanation as to how reimbursement will be generated for all the new CDT-2005 diagnostic procedure codes.
Let's evaluate just two of the new and/or redefined codes that we have to look forward to in the new year. The new kid on the block is a specific code for the technique-sensitive "brush biopsy." According to CDT-2005, D7288-Brush Biopsy, Transepithelial Sample Collection - Collection of oral disaggregated transepithelial cells via rotational brushing of the oral mucosa. The ADA did nothing more than revise the original code definition of D7287 and replace it with the above-referenced grammatical redefinition. I don't know about you, but I know my seventh-grade composition teacher, Sister Mary Muckenfutz, is sure glad the profession is no longer referring to a brush biopsy as a "simple cytology sample collection."
Redefined with CDT-2005 is D0415 - Collection of microorganisms for culture and sensitivity. Although the procedure is not specified to be "by report," the narrative should state why the test is being performed. Many available tests check for the presence and concentration of bacteria which cause periodontal disease. A negative test should indicate the disease in the treated area has responded clinically and satisfactorily to therapy. These tests provide good documentation of a patient's microbial status confirming the endpoint of therapy.
Tests to identify names and concentration of pathogens are used to determine the necessity of therapy, type of technique required, and clinical response to endpoint of therapy. To more accurately identify the criteria for the use of code D0415, I will use a brief clinical example. The patient in question is a 20-year-old female who presented in your office with a clinical diagnosis of full-blown, Type I gingivitis. Radiographic review confirms no loss of bone, and the detailed periodontal chart indicates no loss of periodontal attachment. Present throughout the mouth are three-millimeter pseudo pockets. This pocketing is clearly due to inflammation, and not the loss of attachment/bone. There is a complete four-quadrant loss of stippling with inflammation and ulceration of several interdental papillae. The patient's plaque and calculus buildup appears excessive, so the hygienist must carefully scale the teeth while not unduly engaging the inflamed periodontal tissue. Prior to January 1, 1995, the prescribed procedure would have been known as 04345. Now, it must be coded as D4999 (Unspecified Periodontal Procedure, By Report), and include a detailed narrative, perhaps supported by accompanying diagnostic photo, since radiographs do not confirm.
The full-mouth procedure is completed in a single visit. The patient is instructed to return the following week to conclude therapy with a prophylaxis (identified with code D1110). Upon the patient's return, the doctor must first evaluate the patient. In our clinical example, the patient returns with a condition as bad as the one prior to the previous week's scaling procedure. As a result, the evaluation process must start over again.
You take a swabbing of the inflamed gingiva (saliva) and send it off to a university and/or private laboratory for evaluation. The results of the culture confirm the presence of pathogens not native to the oral cavity, but rather to the upper gastrointestinal tract. You now have a completely different course of treatment due to the need for pharmaceutical intervention not normally required. Bacterial flora of oral origin are expected. The fact that certain colonies of oral bacteria are found in extremely high concentrations is of little or no liability to the carrier contract (medical or dental). The carrier would not pay for the testing - Code D0415 - even though there is an increased risk and responsibility for the clinician ito deliver necessary therapy. However, in our example, the bacteriological culture has revealed gastrointestinal flora normally foreign to the oral cavity environment. The testing and lab report become liabilities of the carrier contract, because a lab report showing the presence of bacteria not usually found in the oral cavity would justify an alteration in the treatment plan and the application of atypical pharmacotherapy.
The bacteriologic study just described is one proper application of Code D0415. Another variation would occur if, in fact, you processed and were able to identify the specific nature of the culture yourself.
This procedure is routinely billed to the payer/patient at the same amount charged to you by the testing facility. A separate service charge is not added. When billing a third-party payer, always include a copy of the pathology report and invoice.
Good luck with all the wonderful new procedure codes! Just don't hold your breath too long looking for the patient's benefit plan to write you a check.
Tom Limoli Jr. is the president of Atlanta Dental Consultants and the editor of "Dental Insurance Today," a bimonthly publication that addresses third-party reimbursement in the dental office. He also is the author of "Dental Insurance and Reimbursement Coding and Claim Submission." He can be contacted by phone at (404) 252-7808. Visit his Web site at www.LIMOLI.com.