3 tips for accurate dental coding

What are CDT codes?

Each Current Dental Terminology (CDT) code is a set of three written components for dental procedures that cover oral health and dentistry. The components are as follows:

1. The procedural code is a five-character alphanumeric code beginning with the letter D that identifies a specific procedure and is followed by four numbers.
   
   
2. The nomenclature is the written title of the procedural code.
   
   
3. The descriptor is a narrative that defines the nature and intended use of the single code. A descriptor can apply to a series of codes in a set.

Due to annual changes by the ADA’s Coding Committee and advancing integration into medical diagnosis, CDT coding can be complicated. It's essential to be familiar with how the codes were developed.

Knowing the basics of creation provides clues as to where to look for the correct code for the procedure. It's more than just picking the correct code. It's knowing what's behind the code, like a code's backstory relating to your patient.

Whether it's a complex treatment plan, an uncommon diagnosis, or a patient with unique insurance coverage, confusing dental coding scenarios can cause headaches and delays in filing and reimbursement.

Let's break it down into small bites to understand the process better. Here are a few tips to help you.

Tip No. 1: Determine the code for what was performed

Have the current coding books available for the clinical and insurance team.

You just repaired a tooth and are seeking a code that matches what you did. Ask the following questions to confirm the facts before choosing a code:

• What is the area of the oral cavity where the tooth is located?
  
  
• What is the identifying tooth numbering system? Is it universal or another system?
  
  
• What is the tooth number? Teeth are identified by a number or a letter (as in primary teeth) -- check for shifting or supernumerary teeth affecting the correct order in the jaw. Recording the wrong tooth number will create problems in the record and billing insurance plans.
  
  
• What is the tooth surface(s) involved? Multiple surface restorations must be appropriately coded in your records and the corresponding insurance claim form.
  
  
• What is the description of the procedure? What was performed, and what materials were used? The information is necessary to choose the matching code.
  
  
• What teeth are missing? Does this match the supporting documentation? Chart all missing teeth information on the patient's chart.

There may be more than one applicable code, but one is usually more accurate.

Tip No. 2:  Determine the category of service the procedure falls under

The codes are created in categories for easy lookup in the CDT manual. Documenting services often requires the selection of codes from different service categories -- see the alphabetic index of the ADA CDT code. Become familiar with all of the coding categories.

In billing dental insurance claims, codes should not be chosen based on what will get paid. The rule is to code what you do.

The following types of service categorize the CDT Code set:

• Diagnostic: D0100-D0999
  
  
• Preventive: D1000-D1999
  
  
• Restorative: D2000-D2999
  
  
• Endodontics: D3000-D3999
  
  
• Periodontics: D4000-D4999
  
  
• Prosthodontics/removable: D5000-D5899
  
  
• Maxillofacial prosthetics: D5900-D5999
  
  
• Implant services: D6000-D6199
  
  
• Prosthodontics/fixed: D6200-D6999
  
  
• Oral and maxillofacial surgery: D7000-D7999
  
  
• Orthodontics: D8000-D8999
  
  
• Adjunctive general services: D9000-D9999

When you read what was performed in the clinical notes, you can go directly to the category in the coding manual to find the correct code match. 

Tip No. 3: Use the ‘unspecified procedure by report’ code when you cannot find an appropriate CDT code

If the dentist cannot find a CDT code that fits the procedure description, use the "unspecified procedure by report" code -- do not use an "in-house" code or a code that is made up to fit the situation.

The CDT manual has unspecified procedures at the end of each category, which are referred to as the “999 codes.” For instance, if you perform a restorative procedure that does not match any of the codes under the restorative category, you may use the code D2999: Unspecified restorative procedure by report; however, you must describe the issue and procedure in a narrative or the attached clinical notes for insurance documentation.

Dentists determine what services (procedures) are delivered to a patient. As published in the ADA CDT manual, the full CDT code entry must be considered when determining which dental procedure code to document the services provided. The code description provides the information a dentist needs to decide which code most accurately describes the procedure.

Many dentists and their clinical teams have yet to learn to use the CDT codes to the maximum advantage in documenting patient services. The service is often left out of the clinical notes if there isn't a fee on the usual or standard fee schedule.

Also, it must be documented if the insurance company providing benefits doesn't cover a particular code. The following are some procedures normally performed but which are not recorded in clinical records or billed to insurance companies. Whether the service is charged or not or paid by insurance, it should be included in the patient's record:

• D0191: Assessment of a patient
  
  
• D0350: 2D oral/facial photographic image obtained intraorally or extraorally
  
  
• D1310: Nutritional counseling for control of dental disease
  
  
• D1320: Tobacco counseling for the control and prevention of oral disease
  
  
• D1330: Oral hygiene instructions
  
  
• D1353: Sealant repair
  
  
• D4921: Gingival irrigation with a medicinal agent per quadrant
  
  
• D5986: Fluoride gel carrier
  
  
• D9311: Consultation with a medical healthcare professional
  
  
• D9430: Office visit for observation (during regularly scheduled hours)
  
  
• D9630: Drugs or medicaments dispensed in the office for home use
  
  
• D9910: Application of desensitizing medicament
  
  
• D9932: Cleaning and inspection of the removable complete denture, maxillary
  
  
• D9933: Cleaning and inspection of the removable complete denture, mandibular
  
  
• D9934: Cleaning and inspection of removable partial denture, maxillary
  
  
• D9935: Cleaning and inspection of removable partial denture, mandibular
  
  
• D9975: External bleaching for home application, per arch 

The proper creation of outstanding clinical records includes all services provided to the patient.

Proper records create the backstory of the patient's history of care and help the dentist choose the right course of treatment for the patient and the proper codes for the clinical situation.

Dr. James V. Anderson is a practicing dentist in Syracuse, UT, and is the CEO and founder of eAssist Dental Solutions. He can be reached via email.

The comments and observations expressed herein do not necessarily reflect the opinions of DrBicuspid.com, nor should they be construed as an endorsement or admonishment of any particular idea, vendor, or organization.