RECAP: Coding Update 2018

Blog | By VYNE

Presented by Teresa Duncan, MS, founder of Odyssey Management

“The 2018 Dental Coding Update” webinar presented by NEA and industry insurance expert, Teresa Duncan, M.S., founder of Odyssey Management, held Jan. 9, 2018, drew a live audience of 869 attendees with more than 1,767 people registering for the event sponsored by NEA Powered by Vyne. Attendees learned about changes to dental codes for diagnostic, preventive and restorative procedures, as well as endodontic, periodontic, prosthetic, implant, oral/maxillofacial, orthodontic and adjunctive procedures.

Duncan explained why there are so many coding changes, who decides what gets changed and what the future areas of focus may include. As times and technologies have changed in dentistry, so have the materials being used for gingivectomies and implants, for example, as well as the rise of teledentistry. As new materials and procedures arise, so does the need for the coding to support them – hence the annual coding updates.

“Some revisions can be puzzling and some revisions are long overdue,” said Duncan.

Each practice must review and note the changes for codes most often used and evaluate how they are affected. She added that, “The one constant through all of the changes, is the fact that we need really good documentation in order to make the codes work in our offices.” She also reminded attendees that their practice’s revenue will be directly related to how well they are documenting their procedures.

Why coding changes

Codes change every year as a way for practices to respond changes within the industry. Every year, a score of organizations meet in Chicago to review codes and make changes to them, as needed. Most of the industry’s leading groups are present (payers, associations, providers), including the Centers for Medicare and Medicaid Services (CMS). The coding updates help target new ways to create efficiencies for receiving reimbursements and addressing new procedures. There are changes in materials and even technologies, like teledentistry, that must have corresponding codes to adapt to sector evolutions, as well as new ways to submit claims and process payments.

Accurate documentation leads to less problematic reimbursement. Today’s successful offices realize that revenue is tied directly to how well you document. If you have poor documentation processes, the requests for information and appeals will be considerable. It’s best to make sure you are documenting well to begin with.

Deleted codes

This year brings us three deleted codes: D5510, D5610, D5620.

Coding additions

  • D0411 is in-office point of service testing, testing patients for diabetes.

This coding addition indicates a huge shift in that dental practices are now treating patients as a whole and not just the mouth. High-risk patients will receive the test, including obese or overweight, those of certain ethnic backgrounds that put them at risk; those with a sedentary lifestyle, and those with a family history. This is a screening effort beyond simple dental care.

Rather than picking and choosing who gets the test, many practices will test everyone. Duncan advises to follow the proper protocol for administering the test because it involves government regulation. First, check your state to see if you can perform this according to your license, but you also have to do your own homework: Who can do this? Dentist, yes. What about hygienist or certified dental assistant?

Next, to carry out this test, you need to register with the government because you will be collecting samples. While this requires that you be certified as a lab, most practices will seek a waiver. The waiver comes with $150 fee and many forms. The American Dental Association (ADA) has published a guideline for this. You can find it on their site.

Finally, will D0411 be reimbursed? In some cases it may, but this likely will vary. You may be able to seek additional cleaning payment coverage for individuals affected by this, but documentation is required as to whether it supports this procedure.

Preventive revisions

  • D1354 – interim caries arresting medicament application – changed to add “per tooth”; conservative treatment of an active, non-symptomatic caries lesion by topical application of a caries arresting or inhibiting medicament and without mechanical removal of sound tooth structure. Check licenses for whether you can perform this code. This is not per lesion, but per tooth.

Coverage does vary and it might be considered “experimental” at this stage. You also need to check on the license for who can perform the procedure.

Preventive and Restorative Revisions

  • D1555 – removal of a space maintainer – procedure performed by dentist or practice that did not originally place the appliance. The code maintenance committee closed the double billing loop, likely because of an uptick in billing by practices. For example, within one practice a doctor would bill the start of the procedure and another would bill out its completion. Documentation must match and support how and what is coded.
  • D2740 – Crown – porcelain/ceramic – took out “substrate” portion of the coverage.

Endodontic revision

The term “bicuspid” was removed and replaced with “premolar” to keep practices in line with the code book.

Regarding endodontics, there seems to be an uptick in required documentation. For example, practices are being asked for more pre-operative images and post-operative images. Any intraoral images may also be of benefit to a practice.

  • D3320
  • D3330
  • D3347
  • D3421
  • D3426

Periodontics Revision

  • D4230 – anatomical crown exposure – four or more contiguous teeth or bounded tooth spaces per quadrant
  • D4231 – anatomical crown exposure – one to three teeth or bounded tooth spaces per quadrant

This procedure is utilized in an otherwise periodontally healthy area to remove enlarged gingival tissue and supporting bone to provide an anatomically correct gingival relationship.

  • D4355 – Full mouth debridement to enable a comprehensive oral evaluation and diagnosis “on a subsequent visit.”

Prosthetic Additions

  • D5511 – repair broken complete denture base, mandibular
  • D5512 – repair broken complete denture base, maxillary
  • D5611 – repair resin partial denture base, mandibular
  • D5612 – repair resin partial denture base, maxillary
  • D5621 – repair cast partial framework, mandibular
  • D5622 – repair cast partial framework, maxillary

Implant Addition

  • D6096 ‐ Remove broken implant retaining screw. This is a new code.
  • D6116 ‐ Implant/abutment supported interim fixed denture for edentulous arch–mandibular.
  • D6118 ‐ Implant/abutment supported interim fixed denture for edentulous arch – maxillary.

Used when a period of healing is necessary prior to fabrication and placement of a permanent prosthetic.

Implant Revision

  • D6081 – Scaling and debridement “in the presence of inflammation or mucositis” of a single implant, including cleaning of the implant surfaces, without flap entry and closure. This procedure is not performed in conjunction with D1110, D4910 or D4346. This is not a catch-all for cleaning a patient that has implants.

Oral and Maxillofacial Surgery Additions

  • D7296 – corticotomy – one to three teeth or tooth spaces, per quadrant
  • D7297 – corticotomy – four or more teeth or tooth spaces, per quadrant

This procedure involves creating multiple cuts, perforations or removal of the cortical, alveolar or basal bone of the jaw for the purpose of facilitating orthodontic repositioning of the dentition. This procedure includes flap entry and closure. Graft material and membrane, if used, should be reported separately.

Review costs for the procedure to set your costs for these codes appropriately.

  • D7979 – nonsurgical sialolithotomy: A sialolith is removed from the gland or ductal portion of the gland without surgical incision into the gland or the duct of the gland; for example via manual manipulation, ductal dilation, or any other non-surgical method.

Oral and Maxillofacial Surgery Revision

  • D7111 – extraction, coronal remnants – primary tooth (“Deciduous” changed to “primary”).
  • D7980 – surgical sialolithotomy. Procedure by which a stone within a salivary gland or its duct is removed, either intraorally or extraorally.

Orthodontics Additions

  • D8695 – removal of fixed orthodontic appliances for reasons other than completion of treatment: an appliance in the mouth, but removed temporarily; not a permanent removal.

Adjunctive Additions

  • D9222 – deep sedation/general anesthesia – first 15 minutes. This is in line with how medical bills. Anesthesia time begins when the doctor administering the anesthetic agent initiates the appropriate anesthesia and non-invasive monitoring protocol and remains in continuous attendance of the patient. Anesthesia services are considered completed when the patient may be safely left under the observation of trained personnel and the doctor may safely leave the room to attend to other patients or duties.

The level of anesthesia is determined by the anesthesia provider’s documentation of the anesthetic effects upon the central nervous system and not dependent upon the route of administration.

  • D9239 ‐ intravenous moderate (conscious) sedation/analgesia -‐ first 15 minutes. Anesthesia time begins when the doctor administering the anesthetic agent initiates the appropriate anesthesia and non‐invasive monitoring protocol and remains in continuous attendance of the patient. Anesthesia services are considered completed when the patient may be safely left under the observation of trained personnel and the doctor may safely leave the room to attend to other patients or duties.

The level of anesthesia is determined by the anesthesia provider’s documentation of the anesthetic effects upon the central nervous system and not dependent upon the route of administration.

  • D9223 ‐ deep sedation/general anesthesia – each subsequent 15-minute increment.
  • D9243 ‐ intravenous moderate (conscious) sedation/analgesia – each subsequent 15-minute increment.
  • D9995‐ teledentistry – synchronous; real‐time encounter. Reported in addition to other procedures (e.g., diagnostic) delivered to the patient on the date of service.
  • D9996 ‐ teledentistry – asynchronous; information stored and forwarded to dentist for subsequent review. Reported in addition to other procedures (e.g., diagnostic) delivered to the patient on the date of service.

An update on D4346

D4346: scaling in presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation. The removal of plaque, calculus and stains from supra‐ and sub‐gingival tooth surfaces when there is generalized moderate or severe gingival inflammation in the absence of periodontitis. It is indicated for patients who have swollen, inflamed gingiva, generalized suprabony pockets, and moderate to severe bleeding on probing. Should not be reported in conjunction with prophylaxis, scaling and root planing, or debridement procedures.

This code, per Duncan, has been a great addition, but some practices are not getting paid their full fee for the procedure. The code is often covered at the prophylaxis benefit level. To cover this shortfall, practice admins may wish to tell patients that there is a chance that they will have to cover the procedure beyond the insurance coverage of the code. In the long run, however, the code is much needed, she added. The ADA also has a useful guide for this procedure code on its site.

Appropriate Use of D4346

  • Thirty percent or more of teeth are involved (generalized)
  • Not measured by time or difficulty
  • Not to be used as an intermediate step between D1110 and D4341/D4342
  • Used after an evaluation and diagnosis is made

There’s even more to know

At the end of every year, practices must update their systems and download the appropriate code patch so that old codes are deleted and the new codes uploaded. Duncan also recommends such resources as the ADA’s “CDT 2018,” Dr. Blair’s “Coding with Confidence” and her book on patient insurance conversations, “Moving Your Patient to Yes!”

Additionally, she recommends using electronic attachment technology services to simplify claim processes and ensure that proper documentation is included with claims up-front. Tools like FastAttach and FastLook from NEA enable providers to identify in advance codes that require certain types of attachments for particular payers and enable practices to securely submit all required documentation at the time of the initial claim submission.

While the previous content mentioned here is comprehensive, Duncan said, as usual, the code set continues to evolve.  While the information is detailed, there is even more to learn to navigate the complicated world of dental coding, including the surge of payer disallows and practices choosing to leave plans in certain instances because of agreements that are too restrictive. Staying abreast of changes to the codes and of the industry are necessary for today’s successful insurance practice.

To hear Duncan’s complete coding review, listen to the free webinar here: https://register.gotowebinar.com/register/526866563998332675