Concerns about dental codes and their capacity to accurately label various procedures for insurance purposes are a major source of concern for many dental practices. It is vital to use the correct dental codes, but that can quite often be complicated; the primary reason why most dentists choose to hire DentalRevu to streamline their backend operations.
While medical coding is based on Current Procedural Terminology (CPT), dental medical billing codes utilize Current Dental Terminology (CDT), which is maintained by the American Dental Association (ADA), provides all of the dental treatment codes necessary for properly coding each dental procedure(s) for submission to a particular dental insurance plan.
What are CDT Codes?
CDT Codes are a series of medical codes for dentistry and oral health operations. Each procedural code is a four-digit alphanumeric code that begins with the letter “D” (the procedure code) and ends with four digits (the nomenclature). Additionally, it offers written descriptions of certain procedural codes.
The CDT list enables quick access to dental procedure codes at any time, but most dentists will still have some questions about this ADA intellectual property. In light of this, ADA does offer plenty of education material, so that concerns of dentists can be addressed and rectified.
The ADA has built a comprehensive reference library for dentists that includes coding educational materials. You’ll even find videos, webinars, and PDF guides that take an in-depth look at various services that are documented and reported using their own unique CDT Codes.
These materials are available for purchase through the ADA Store and can be found on the ADA’s Coding Education web pages, which include:
- CDT 2022: App for iOS and Android
- CDT 2022: Dental Procedure Codes and App Kit
- CDT 2022 Companion: Training Guide for the Dental Team
How are CDT Dental Codes Categorized?
One significant distinction between CPT and CDT is that nothing in the CDT supports or indicates a restriction on the use of codes assigned by dentists—generalists, specialists, or hygienists—to any categorical section(s) of the CDT Code. To further explain how CDT Codes work, it’s vital to understand how they’re categorized:
- Removable Prosthodontics
- Maxillofacial Prosthetics
- Implant Services
- Fixed Prosthodontics
- Oral and Maxillofacial Surgery
- Adjunctive General Services
How are CDT Dental Codes Determined by Practices?
To assign dental insurance codes from the CDT, the patient must have access to dental insurance. If the patient does not have dental insurance, none of the procedures will be covered. Many individuals expect that their medical insurance will cover dental services as well.
It is critical to consider the sort of coverage that each patient possesses before diving deep into the dental codes for billing a client. If the patient receives dental care that is “connected” to a medical condition(s), the patient’s medical insurance may be billed, depending on the nature of the policy coverage.
This means that the patient can receive the same treatment at either their dental or medical office, but will be billed by different insurance carriers. While we understand that there is no black or white for assigning codes, most medical plans eliminate coverage for any treatment involving “teeth.”
Typical payor language says that neither a physician nor a dentist would be compensated for services related to the care, treatment, filling, removal, or replacement of teeth. The exemption is confined to treatment of sound natural teeth or components directly supporting the teeth as a result of urgent accidental harm.
Additionally, certain medical insurance will cover specific clinical procedures, as well as TMJ and dental implant-related disorders. Typically, a dental claim is submitted first, followed by a medical claim if the dental claim is denied. It’s due to these many “regulations” why most dentists choose to outsource their dental billing.
How are Dental Claims Submitted Using CDT Codes?
While medical claims are made using their own form (CMS 1500), dental claims are made using the J400 form. This form is developed exclusively to collect dental information. Dental claim forms must include the following dental information:
- Area of oral cavity
- Tooth system
- Tooth number or letter
- Tooth surface
- Description of procedure
- Missing teeth information
Note: When the dentist or dental hygienist performs the essential procedures, this information is incorporated, and it is mentioned on the dental claim.
Frequently Asked Questions (FAQs) about Dental Codes
If you still face difficulty in understanding how Dental CDT Codes work, we have answered some common questions instigated by dental professionals, practitioners, and dentists from all over the United States. These should help answer some recurring concerns regarding the dental billing industry as a whole:
Why is the CDT Code Updated Annually?
Dental practices are always evolving, and the CDT Code provides a way for dentists to document the services they perform. The CDT Code can successfully allow that evolution thanks to annual revisions. The ADA is obligated to review the CDT Code annually by the HIPAA national standard for electronic claims transactions.
Who Requests Additions, Revisions, or Other Changes to the CDT Code?
You do – Dentists are a major source of requests for additions and adjustments because they are the primary providers of dental treatment. Requests are also received from the American Dental Association’s Council on Dentistry Benefit Programs, dental specialty organizations, third-party payers, and other members of the dental community. Because the maintenance procedure is open to anybody who is interested, “how-to” and “when” information is available online at the CDT Code website.
How Do I Determine the CDT Code to Document the Service I Provided?
Clinical decisions made by a dentist dictate which treatments (procedures) are provided to a patient. When deciding the dental treatment code to utilize to document services rendered, the whole CDT Code entry, as published in the CDT manual, must be considered.
The code and its nomenclature are presented in boldface font in a process code entry. Descriptors for some process code entries are also printed in standard typography. A careful study of the code entry should provide enough information for a dentist to determine which code best describes the procedure.
Note: Codes should not be chosen solely on what will bring in the most money.
Why Isn’t There a CDT Code Associated with the Procedure I’m Providing Today?
Occasionally, the delivery of new or changed dental operations and the CDT Code maintenance process are out of sync. The transition to annual CDT Code updates aides in the consistency of procedures and documentation. Nonetheless, there will be instances when, in the dentist’s perspective, no CDT Code entry adequately represents the service delivered.
This is when a CDT Code for “unspecified…procedure via report” may be considered (e.g., D2999 unspecified restorative procedure, by report). All procedure codes that begin with “by report” must include documentation that specifies the service performed. Additionally, this is an opportunity for you to submit a request for CDT Code action to close the gap.
Whom Should I Contact for Additional Information Regarding the Claim Submission or CDT Code?
Your first point of contact should be the ADA Member Service Center (MSC). Complex issues are directed to the Practice Institute’s Center for Dental Benefits, Coding, and Quality staff. To reach the MSC by phone, call the toll-free number on the back of your membership card, 312-440-2500, if you are an ADA member. Requests can also be emailed to email@example.com.
Is There Any Further CDT Code Information Available Online?
On the Coding Education web pages, you can view or download free webinar recordings and instructions to various operations and corresponding CDT codes. Case management services, scaling in the presence of gingival irritation, and teledentistry events are among the topics and codes covered.
Why Aren't All CDT Code Procedures Covered by Third-Party Payers?
The CDT Code is a taxonomy that facilitates the codification of professional services. A dental benefit plan reflects the purchaser’s choice of which services are covered for the cost of the plan. This is why dental benefit plan agreements include clauses on coverage limitations and exclusions.
Doesn't HIPAA Require a Third-Party Payer to Cover Every Procedure Code on a Claim Submission?
No, HIPAA’s administrative simplification provisions are confined to information sharing between the sender (e.g., a dentist/practitioner; provider) and the recipient (e.g., a dental benefit plan/third-party payer).
According to HIPAA, information must be shared in a standard format and with particular code categories, including the CDT Code. The administrative simplification provisions of HIPAA do not govern what you do in your practice or what a payer does in its individual claim adjudication policies.
Why Isn't the CDT Code Available to Members for Free?
The ADA’s intellectual property, the Code on Dental Procedures and Nomenclature, is critical and valuable, and it requires high maintenance expenditures. Non-dues revenue, such as CDT publication sales and licensing, is seen by volunteer leadership as a way to pay some of the maintenance costs.
How are the CDT and ICD Codes Related?
CDT and ICD codes are both HIPAA-compliant standards that apply to electronic dentistry claims. ICD (International Classification of Diseases – 10th Edition – Clinical Modification) is the only diagnosis code set that may be used on dental benefit plan claims when necessary, as well as on medical benefit plan claims for dental services that always require diagnosis codes.
Consider the following examples of regularly reported CDT codes that correspond to one or more ICD-10-CM diagnosis codes. The ADA Council on Dental Benefit Programs’ Code Maintenance Committee is responsible for maintaining the CDT Code. ICD is maintained by federal government entities.
What is the Link Between SNODENT and the CDT Code?
Each of these code sets has a distinct purpose, however they do overlap in one area. The CDT Code enables dental treatments to be documented and reported in a standardised manner. It is a HIPAA-compliant standard for electronic dental claims.
On the other hand, SNODENT (Systemized Nomenclature for Dentistry) promotes the codification of the patient’s condition (e.g., diagnosis and findings) and other variables that may affect therapy. It is not a HIPAA-compliant standard and so cannot be reported on dental claims.
The CDT Code and SNODENT are similar in one respect: both are approved by federal authorities as code taxonomies for use in dental patients’ electronic health records.
Why Do I Need a CDT Manual If My Practice Management System Provider Offers Me a Procedure Code Update?
The CDT Manual contains information that is frequently excluded from software updates – a thorough list of procedure code nomenclature and descriptor changes, as well as complete nomenclature and descriptors for each CDT Code entry. Practice management systems commonly truncate this information, making it more difficult to select the correct code.
What Exactly Is an Explanation of Benefits, and Can Different Procedure Codes Be Reported on Claims?
An EOB is a statement from your health insurance plan that describes the expenditures it will reimburse for medical care or products that you have received. When your provider submits a claim for the services you received, an EOB is generated.
An explanation of benefits that shows compensation for less services or different procedure codes than those recorded on the claim raises concerns and encourages dentists to contact the ADA and inquire, “How is this possible? Is the third-party payer engaging in any illegal or unethical behaviour? It appears that the CDT Code is being abused.”
The first step in addressing these questions and concerns is to examine the existing CDT Code advice.
- A third-party payer must utilize the code number (e.g., Dxxxx), nomenclature, and descriptor exactly as provided. The ADA wants to know about any instances where the payer modified any of them.
- Procedure code bundling is defined by the American Dental Association as “the systematic merging of discrete dental treatments by third-party payers that results in a lower benefit for the patient/beneficiary.”
- The ADA frowns on procedure code bundling. Dentists who have signed participating provider agreements with third-party payers, on the other hand, may be bound by plan rules that limit or eliminate coverage for concurrent operations.
- According to the Health Insurance Portability and Accountability Act (HIPAA), the procedure code reported on a claim must be from the CDT Code version that is in force on the date of service.
- Nonetheless, neither HIPAA, ADA policy, nor the CDT Code mandate a third-party payer to fund every listed dental procedure. The contract between the plan purchaser and the third-party payer specifies which dental operations are covered.
Many patients are unaware of how dental benefit programs operate or that coverage limitations and exclusions may limit reimbursement for important care. Such a misconception is exacerbated when the EOB language implies that the dentist is at fault. Ensuring that patients understand the limitations of their dental plan before treatment may aid in the avoidance of difficulties and the maintenance of a solid dentist-patient relationship.
Some dental claim adjudication techniques are appropriate when based on plan design and should be mentioned clearly on the EOB to avoid misunderstandings. Other scenarios in which the EOB notification indicates that the dentist made a mistake may be problematic. Each of these situations is demonstrated in the examples below:
- Acceptable EOB Explanation: A claim for “D4355 full mouth debridement…” and a two-surface restoration is assessed, with reimbursement for only the D4355. The EOB letter notes that the benefit plan contains limits and exclusions, one of which is that any restorative procedure performed on the same day as a D4355 is not covered by the plan. In this instance, the payer has declined to pay for the surgery owing to benefit plan design constraints — there is no indication that the dentist acted improperly.
- Unacceptable EOB Explanation: The dentist reports a D1110 on the claim because the patient is 13 years old and has mostly adult dentition, while the EOB cites D1120 as the right code for a patient under the age of 15. The payer is incorrect in this instance, as the notice implies that the dentist submitted the incorrect prophylaxis treatment code. In this case, the payer disregarded the CDT Code’s description, which states that the criterion for reporting adult vs child prophylaxis is dentition, not age. When a benefit plan provides an age-based benefit limitation, the payer should accept the claim as presented and mark on the EOB that the claim has been adjudicated in accordance with the benefit plan’s design.
Note: The final example demonstrates why it is critical for the dentist office to assist the patient in comprehending the clinical rationale for treatment. The type of prophylaxis is defined in this case by the state of the patient’s dentition, not by age, even though the patient’s benefit may be dictated by age.
How Do I Code My Claim to Ensure I Am Paid Quickly and Correctly?
Firstly, ensure that the codes in your claim are accurate, which entails utilizing the most recent version of the CDT Code in effect on the date of service and coding for the services rendered.
When a claim is received with the erroneous code for a stated treatment (for example, utilizing single unit crown codes with a pontin), the benefits administrator has the option of denying the claim or changing the code to reflect the service actually delivered.
While accuracy in submitting the treatment code is crucial, so is accuracy in entering the patient’s personal information, which includes the patient’s birthday, Social Security number, and insurance policy and group numbers. Secondly, ensure that all necessary documentation is included.
Radiographs must be diagnostic in nature and clearly labelled with the patient’s name and the date of exposure. Provide periapical pictures for crowns or onlays-treated teeth. Periodontal charting and radiographs are frequently asked to determine periodontal therapy.
While photographs are beneficial as a supplement to radiographs, they do not completely eliminate the necessity for radiographs. Narratives should be succinct and convey the diagnosis or rationale for doing a procedure. In 2012, the American Dental Association revised the ADA Dental Claim Form to include boxes 34 and 34a for recording diagnostic codes.
While it is not required to include diagnostic codes on the claim form, particularly when submitting claims to a few states’ Medicaid agencies, certain payers grant additional coverage for specific documented diseases.
Thirdly, ensure that the administrative staff of your office has a functional grasp of the patient’s insurance coverage. This can assist to avoid unpleasant surprises, like as a bridge that is not covered owing to a missing tooth clause or a crown that is not covered since the old crown was placed less than five years ago.
How Many Dental Codes Are There in Total?
According to the American Dental Association’s Dental Codes List, there are a total of 760 unique Dental Codes in the Code on Dental Procedures and Nomenclature, abbreviated as the CDT Code. Each procedural code is a four-digit alphanumeric code that begins with the letter “D” (the procedure code) and ends with four digits (the nomenclature). For instance:
- D0120 – A complete series (D0210) aids in establishing a diagnostic baseline. The entire series is often repeated every three to five years, depending on the patient’s needs.
- D7210 – Confidently coding extractions; extraction, erupted tooth needing bone removal and/or tooth sectioning, and elevation of mucoperiosteal flap, if indicated.
- D0431 – D0431 is a visual cancer detection screening test, not a biopsy, which is coded differently (possibly D7288 brush biopsy which harvests transepithelial cells).
- D4249 – Crown Lengthening-Hard Tissue; a surgical type procedure performed on a tooth with healthy periodontium (that means no perio disease).
- D0140 – D0140 is an evaluation code that is restricted to “one evaluation per six months” or “two evaluations per year” rule from the CDT.
- D2740 – D2740 may now be used to report any porcelain or ceramic crown. The word “substrate” has been removed from the nomenclature.
Why Should You Outsource Your Dental Billing to DentalRevu?
Depending on the number of patients you serve on a monthly basis, the amount of effort required to process claims, send EOBs, contest denied claims, and keep your over-ninety days insurance receivables to a minimum varies and may frequently become extremely frustrating.
By hiring DentalRevu, you can streamline your operations. We offer full-scale dental billing services with all the top industry professionals onboard and have a knack for providing quality services with proven strategies at hand.
With superior practices and failsafe dental insurance verification, we help you get rid of all your patients’ frustrations and increase their satisfaction. Our tech-driven, future-focused solutions help you save time, earn more money, and feel less stressed.
With so much on dental administrators’ plates on any given day — scheduling, treatment planning, marketing, and cross-training, to name a few — it’s unsurprising that 70% of dental practices do not collect the entire amount, due on insurance claims owing to missing dental billing processes.
Add this to the highly complicated clauses of various dental codes and things get more difficult than usual. Outsourcing your dental billing operations to a reputable provider like DentalRevu entails adding dental billing experts to your team who work directly with you to collect the entire amount due by insurance companies.