Code Red: What Dental Codes to Use in Different Situations

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Sometimes it feels like we need a code red to determine which code best suits our patient’s particular dental condition. I am sure we have all been there. Do we use D4355 for Debridement or just start with D4341 or D4342? Do I use the Gingivitis code D4366 or just fight through a Prophylaxis with the D1110 code and write a narrative explaining the increased price? Throw in the Palliative treatment D9110 code just to confuse us a little bit more.

Why Do We Need Dental Codes?

Current Dental Terminology (CDT) codes are procedure codes created by the American Dental Association (ADA) to achieve uniformity, consistency, and preciseness in accurately documenting dental treatment.1 CDT codes are not made for the insurance companies; rather, for accuracy and consistency in dental documentation.

A common issue with dental coding is lack of coding knowledge. Since insurance companies are code-oriented, and the majority of our patients are insurance-oriented, the two are forever linked. However, if we let insurance companies dictate which codes to use, and how often we can use them, we are doing a disservice to our patients as well as our dental practice. The insurance companies are big businesses that focus on financials; whereas the dental practices are patient-oriented first, and financial second. After all, without happy and healthy returning patients, we wouldn’t have a business to practice in.

Do Not Let Insurance Mandate or Dictate Recommended Treatment

Think of dental insurance as a dental “allowance” and explain to your patients just that. The insurance company uses the ADA coding system as their guide as well. It guides them as to how much dental “allowance” they will dispense in a given year on a code-by-code basis. Therefore, use the ADA codes as recommended by the ADA and be upfront with your patient(s) regarding the necessary dental treatment recommended for a healthy and functional mouth and whole body health.

Be Honest and True

Sometimes we may think we are doing our patients a favor by using the Prophy D1110 code instead of the Gingivitis D4346 code simply because insurance often denies coverage or does not fully cover treatment. Does the Prophylaxis code help that patient gain health? Is that six-month interval enough intervention for an unhealthy mouth? Using the Gingivitis D4346 code and thorough patient education on oral health and homecare with a re-evaluation will most likely have a bigger effect on the dental IQ of that patient than running them through the prophy mill.

Be honest and true to yourself, to your patient, to your licensure, to your employer, and to the insurance company. It is amazing what oral health promotion will do in conjunction with the D4346 code to dissipate problematic gingivitis.

I was recently reading a dental blog discussing payment for SRP. The hygienist probed a mouthful of 4’s with bleeding upon probing, could feel rough root surfaces, and recommended scaling and root planning to her patient. Her employer told her to probe harder to get 5’s on the chart, and her co-worker told her to just fudge the numbers so insurance would pay. Oh my! (Personally, I have never had an insurance company deny SRPs with multiple 4mm probings and B.O.Ps.) My advice is: a 3 is a 3, a 4 is a 4, a 5 is a 5, etc.

In this instance, the hygienist should have stood her ground, used thorough periodontal education to help the patient understand their condition, and presented the appropriate SRP (D4341 or D4342) treatment plan. With digital imagery, we can enlarge and draw on radiographic or intra-oral images prior to submitting the claim to the insurance company to show areas of disease.

Submitting a periodontal narrative with the claim is recommended. If the insurance company declines coverage, then the patient will be responsible. Inform the patient of the full fee, their estimated fee, the insurance company’s estimated coverage, and make sure they are aware of their financial commitment if, for some reason, the insurance denies the claim. Informed consent is key. Honesty is always the best policy.

Fluoride Codes

Just to keep us on our toes, the fluoride codes have changed over the years. Codes D1203 and D1204 have been replaced with code D1208 (child and adult). Since the inception of fluoride varnishes, the way we apply fluoride has changed for most dental offices. Most have traded their sloppy fluoride trays for simple and effective fluoride varnish application. I personally love using fluoride varnish on the majority of my patients. The fluoride varnish code D1206 is the only fluoride code I use as it is appropriate for adult and child and pays better than the D1208. Varnish is my chairside friend!

When a patient presents with extreme sensitivity issues, and restorative treatment has been ruled out, I like to apply a desensitizer prior to the appointment for comfort and apply fluoride varnish upon completion of treatment. This is when I may use the D9110 code Application of desensitizing medicament and add a narrative.

A more recent fluoride that has come to our attention is effective for arresting caries in patients who may not be able to receive or handle restorative treatment (such as the very young, the very old, the physically or mentally unable, or patients with rampant decay to allow the timeline for restorative treatment). Code D1354 Interim caries arresting medicament application, i.e., Silver Diamine Fluoride can be a life-saver if/when used with caution.

Radiographs

An underserved code in this department is the code D0277. Vertical bitewing radiographs should be taken every other year or at least every three years on our periodontal and high caries risk patients. Know your patient’s risks and radiograph accordingly; however, please use the appropriate code regardless of “insurance benefit” or what the front office says. You are the boss of yourself and are responsible for the treatment rendered to your patients. You are the one with the licensure, not the insurance company or the front office.

Exams

Another underused code is D0180: Comprehensive periodontal exam with oral cancer screening.  A comprehensive periodontal exam requires a lot of time, skill, and patient education. This exam should also include visual and palpable cancer evaluation and examination by the dentist. Alternate between codes D0120 and D0180 especially for periodontally involved patients or patients who are high risk for periodontal disease such as patients with heart disease, auto-immune disorders, diabetes, med-induced dry mouth syndrome (xerostomia), and tobacco or marijuana users. Do not feel guilty using the D0180 code. You performed a complex exam – pat yourself on the back!

Periodontics

D4341, D4342, D4346: Use narratives to aid with improved insurance payment.

Some underused codes to consider

  • Nutritional counseling:  D1310
  • Tobacco counseling:  D1320
  • Oral hygiene instruction:  D1330

Medication counseling*:  There is no current code for medication counseling (that I am aware of); however, I believe it is a worthwhile movement to contact the ADA to see about having it added to the coding index.

It is helpful to make a cheat sheet of the codes that you use for quick reference. This aids in quick access to codes that are not used as often. Take time to study your code book to familiarize yourself with the codes that perhaps you should be using and simply did not realize they exist. Review your code book on a yearly basis as they change and evolve annually.

Try not to overwhelm yourself with codes

What may help when consulting proposed treatment with your patient is to discuss WHY certain treatment is recommended, rather than simply educating WHAT treatment is recommended. The WHAT is the code, the WHY is the reason. Why does treatment need to be done? Explain to the patient how their oral health is directly linked to their whole health.

In conclusion, understand what, why, and how you are treating your patients. Realize the value of your treatment and your patients will also realize the value of your treatment. Use the ADA code book for consistency, and do not fear it. The more these codes are used, the more insurance companies will realize their value and start paying for the services performed. ADA codes are simply for dental uniformity in documentation, and not designed for insurance companies to regulate our care.

 

Reference

  1. Code on Dental Procedures and Nomenclature (CDT Code). American Dental Association. Retrieved from https://www.ada.org/en/publications/cdt.
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Rebecca Marie Friend, BS, RDH
Rebecca Marie Friend, RDH, BS, attained her Associate of Applied Science degree in Dental Hygiene from Ferris State University, Big Rapids, Michigan in 1987, where she also met and married her husband. She has been a practicing dental hygienist for over 30 years and has raised three sons while working as a full-time clinical dental hygienist. Rebecca currently practices in Battle Creek, Michigan, for Dr. Earl E. Gaball, DDS, a general and sedation dentist. She resides in neighboring historic Marshall, Michigan. Rebecca is board certified in Nitrous Oxide and Local Anesthesia Administration and is certified in low-level laser therapy. Continuously striving to improve upon her skills and methods of forward-thinking in the dental world, she recently attained her Bachelor of Science degree in Oral Health Promotion through Action Research at O’Hehir University. She is actively involved in a mentorship with students at O’Hehir University. “I take pride in my abilities as a skilled periodontal therapist. I enjoy the patient-practitioner relationship that develops when trust and health are gained, taking mindful care of every individual that I connect with. The benefits of helping others achieve a healthy mouth and regain their confidence with a great smile and healthier self are very rewarding. Whole body health begins with the mouth.” In her free time, Rebecca enjoys visiting the beautiful shores of Lake Michigan where the sunsets are magical, the dunes are stunning, and the rocks are a collector’s delight. She loves to immerse herself in nature whenever she gets a chance and enjoys canoeing, kayaking, nature-walks, flexibility training, yoga, and little “get-a-ways” with her husband. Family life has always been important to her, and now that her three grown sons have spread their wings, she has a little more time to spread hers.