The value and use of diagnosis codes in the dental practice

Diagnosis and treatment planning are arguably the centerpiece of dental practice. Quantifying and recording a patient's complete set of dental and medical diagnoses requires the use of a common coding or reporting system in order to communicate this information to other dentists, physicians, and payors of dental benefits.

David DePorter, DDS.

The coding system used for reporting diagnoses is the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM). Use of ICD-10 codes is supported by the ADA. The ADA now includes both dental- and medical-related ICD-10 codes in its Code on Dental Procedures and Nomenclature (CDT Code) book. Dental schools have included the use of ICD-10 codes in their curricula to prepare graduating dentists for their use in practice.

The use of ICD-10 diagnosis codes in dental practice is still in its infancy period. However, the growing use is directly related to increases in government-related dental benefits programs, such as Medicaid and Medicare. Training and support programs for dental office staff will promote increased use of ICD-10 codes and help dental offices understand how using ICD-10 codes can lead to increased claim filing efficiency. The potential benefits of diagnosis code use in the dental practice are discussed below.

Justified increased frequency of medically necessary services

The use of dental and medical diagnosis codes will add to the growing body of evidence that describes the connection between oral and overall health -- often referred to as the oral-systemic connection. Identifying the presence of chronic medical illnesses can help justify increasing the frequency of dental health services.

For instance, most dental benefit plans limit the frequency of nonsurgical periodontal treatment to one quadrant of the mouth every 24 months and surgical treatment to one quadrant every 36 months. If the reporting of diagnosis codes includes the appropriate classification of periodontitis combined with codes for heart disease, diabetes, or other chronic medical illnesses linked to periodontal disease, then more frequent periodontal treatment can be justified to help improve a patient's health and reduce the patient's overall healthcare costs.

Expansion of dental benefits coverage

Providing more definitive evidence of the oral-systemic connection could help in adding much-needed dental benefits to Medicare Part B and increasing state support for adult benefits in Medicaid programs. The vast majority of seniors in the U.S. do not have dental benefits and have at least one chronic health condition. Evidence of links between dental and chronic health conditions could help change this, and improved dental care can reduce the costs related to the management of age-specific and chronic health conditions.

Reduced authorization requirements

Dental benefit payors typically require authorization review and documentation to support the medical necessity of a requested procedure or service. This process helps prevent fraud, waste, and abuse, as well as unwarranted claim overpayment. Increased ICD-10 use and acceptance will eventually ease the administrative burden on dentists and their staff, as ICD-10 codes will be used to report the medical necessity indication for selected services that previously required authorization and dental record review.

In many instances, rather than requiring the submission of documents to justify medical necessity prior to approval of or payment for a service, ICD-10 diagnosis codes could be submitted on an ADA Dental Claim Form or within the payor's provider portal to justify medical necessity without the need for additional review of x-rays, treatment plans, etc. Ultimately, submitting a code on a claim form will require less staff time than submitting these additional documents.

Although a transition toward ICD-10 reporting and away from requiring medical necessity documentation will not be swift or painless, the associated benefits have been proved in medicine and can work in everyday dental practice. By merging medical and dental conditions, dental practices can demonstrate further support of comprehensive patient-centric care.

The ADA has included a very manageable set of dental diagnosis codes in CDT as of the 2020 publication. It also includes a number of medical-related conditions, including diabetes-associated codes. CDT 2020 and future editions will serve as an easy-to-use reference for dentists and dental office staff.

David DePorter, DDS, has more than 30 years of experience in the dental benefits industry and currently serves as the national dental director for Envolve Health. His role includes dental policy development as well as organized dentistry and state Medicaid program staff relationship development.

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