by Tom Limoli Jr.
Endodontic therapy has greatly benefited from the technological influx of computer-based clinical enhancement. Surgical microscopes, digital apex locators, and the low-speed, turbine-driven, torque-adjustable handpiece routinely accompany simple reamers and files. And by the way, where is your molten metal sterilizer from dental school?
It is not my intention to steal the thunder of our well-respected endodontic specialists, but rather to enhance their marketplace position by providing reimbursement information to help patients make the most of their dental benefit plans.
Too often nonspecialists get into situations beyond their clinical control, with patients financially stuck between a rock and a hard place.
Was the patient informed of the total cost of care, which included the root canal and crown, as well as the potential for a post and core and any unforeseen surgical intervention? How about the “informed consent” that was signed by the patient? Did it cover all the bases?
When all is said and done, the decision to remove the tooth, or use reamers and files, or refer the patient to a higher level of clinical skill rests squarely with the referring general dentist. Heroics should be left to those who do it best — our well-trained, equipped, and supported soldiers in uniform — and then we don’t find ourselves “standing in the field, alone and unsupported.”
Not long ago, endodontic therapy was identified and billed based on the number of involved canals. Gone are those days, and now therapy is identified, billed, and reimbursed based on the treated tooth. Numbers of canals are not specified within the descriptors of an anterior, bicuspid, or molar.
No separate coding exists for the treatment of an ancillary canal, fifth, or sixth root. The completed procedure is identified based on the anatomic position, as well as the type of tooth.
When discussing endodontics, we must not confuse liners and bases with direct and indirect pulp caps. The two (or four) are not related. Bases and liners are part of the completed restoration, while pulp caps, either direct or indirect, are completed and billed prior to the initiation of the final restorative procedure at a later time.
Direct pulp caps (D3110) involve the application of a drug or material to the exposed pulp to stimulate repair of the injured pulpal tissue. Indirect pulp caps (D3120) involve the application of a drug or material to the layer of carious dentin remaining over the potentially exposed pulp to protect the pulp from external irritants.
In all honesty, I do not think the traditional, nonrestorative techniques of direct and indirect pulp caps are part of current operative dental education, and I feel the codes should be removed from current dental terminology. They are worthy of discussion in that they should never be considered routine add-on billings in conjunction with the placement of direct restorations.
Pulpotomy vs. pulpectomy
The terms pulpotomy and pulpectomy are not interchangeable. Therapeutic pulpotomy (D3220) is academically defined as the surgical amputation of the dental pulp coronal to the dentinocemental junction. The complete pulpotomy procedure involves removing the entire contents of the pulpal chamber at the entrance of the root canal(s), while the partial pulpotomy removes only part of the tissue in the pulp chamber. This procedure, be it partial or complete, is a billing entity similar to direct and indirect pulp caps. It is billed in addition to the later completed final restoration.
A complete pulpectomy (D3221) is the removal of both normal and pathologic vital pulp from the pulp chamber of a tooth to the dentinocemental junction at the apex of the root, while the partial pulpectomy removes only part of the contents of the canal. The intent of these procedures is to eventually render the tooth nonvital. Rarely is a pulpectomy not considered the initial step in root canal therapy.
Because the existing code descriptors for D3220 and D3221 are not sensitive to the procedure being partial or complete, it is best to make sure that your clinical documentation far surpasses the inadequacies of the simple code numbers. This will become most critical if the patient is later referred to a higher level of skill for an unforeseen surgical procedure.
In summary, the pulpotomy (D3220) means that the tooth is still alive, while the pulpectomy (D3221) renders the tooth nonvital. Third-party reimbursement for D3220 most often will not occur until the final restoration is placed, while D3221 is often not reimbursed until someone completes endodontic therapy.
As mentioned earlier, endodontic therapy is identified, billed, and reimbursed based on the anatomic position and type of tooth, not the number of involved canals. But can additional ancillary or adjunctive procedures be billed separately in addition to the completed root canal? The answer is both yes and no, depending on the clinical presentation of the specific patient condition.
Intraoperative (during the procedure) radiographs are not billed separately, but the number of adverse clinical findings should always be noted in the patient record. The only radiograph identified, billed, and reimbursed separately is the original evaluation film confirming the diagnosis. The final treatment film that confirms apex closure is actually a working film and should be considered part of the completed procedure.
Procedure code D9110 simply identifies a minor palliative procedure intended to “cloak or mask, but not cure” the painful condition. It is inappropriate to routinely bill for D9110 as the initiation of root canal therapy. This procedure code is best billed when the patient is eradicated of pain by an otherwise uncoded procedure and the next treatment sequence is yet unknown. In other words, when the patient returns or is referred to a higher level of skill, the tooth will either be extracted, endodontic therapy will be initiated, or no treatment will be rendered. Remember, D9110 is a minor procedure with a relatively low fee value.
Of great concern to my moral fortitude is the inappropriate and downright fraudulent billing of code D3351 for the initiation of routine endodontic therapy. What was once old becomes new again when slimy teachers of fraud hold themselves out as would-be consultants. Beware the wolf in sheep’s clothing!
Incomplete endodontic therapy
You started the root canal but were unable to finish, so where do you go from here? Most benefit plans do not consider root canal therapy to be a liability for payment until the procedure is complete. In other words, I recommend that you do not bill the patient’s benefit plan for completed root canal therapy until the canals are sealed. As always, the patient is expected to participate in the cost of care as soon as the procedure is initiated.
If therapy is initiated and during visits the tooth becomes inoperable — not restorable or fractured — our clinical coding criteria leads us to D3332. This code is rarely, if ever, to be used following the submission of D3310, D3320, or D3330. Document in your clinical chart, as well as to the payer, the extent of your efforts. Identify separately the tooth extraction as D7140. If only the root is amputated, use code D3450.
Hemisections are identified as D3920. An additional word of warning: under no circumstances should you bill the benefit plan for this procedure if the patient is not participating in the cost of care.
If endodontic therapy was initiated and the patient simply did not return, I recommend the appropriate use of code D3999 along with a copy of your treatment documentation. Charge 60 percent to 99 percent of your total fee for the intended completed procedure. The same code will probably be used again if the patient returns.
The codes in this section will always require a narrative report to obtain financial participation from the patient’s benefit plan. With endodontic retreatment, our treatment ledgers should specify several key pieces of information. These include:
- Who did the original root canal?
- When was it completed?
- How and what failed?
- How was it retreated?
Most benefit plans will not consider the reimbursement of endodontic retreatment for at least 18 to 24 months from the original completion date. The key word here is completion. In general, higher levels of skill generated by the endodontist will command justifiably higher reimbursement levels.
It is done
The endodontic procedure is now completed. The patient is no longer in pain. The tooth has been saved and the dynamics of occlusion are maintained. But what about the 13-year-old PFM crown you went through to complete the root canal? How do you code the closing of the access hole? What if you added a prefabricated post to help strengthen the tooth?
If you are closing the access hole through a full-coverage crown, the coding is limited to D2980, crown repair. If the access hole is closed with a one-surface composite resin, use the fee for a one-surface composite resin with procedure code D2980.
If you added a prefabricated post along with core paste to add additional retention to the compromised full-coverage crown, use D2950 or D2954 with your submission of procedure code D2980. It’s as simple as that!
Take care and see you on the road!
Tom Limoli Jr. is the president of Atlanta Dental Consultants and 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.