Dental Explorer | Second Quarter 2011 7

Dramatically Cut Coding Errors and Boost Legitimate Reimbursement

Charles Blair, D.D.S.

CODING WITH CONFIDENCE:THE “GO TO” DENTAL INSURANCE GUIDE

CDT-2011/2012 EDITION

PLUSIllustrations

and Error

Correction

Survey

Book sampler: These are sample pages of the book containing front and back cover, table of contents,

explanation of legends, sample full mouth debridement (D4355) code, and index

8 Dental Explorer | Second Quarter 2011

7

TABLE OF CONTENTS

Copyright/Disclaimer/Error Correction Updates Preface

Table of Contents Preface

Introduction 1

Why this Manual is Different 1

Philosophy of Publication 1

Coding Compliance

The Four Levels of Coding Compliance 2

Why Compliance Can Be Painful 3

Surviving an Audit: The Importance of Good Records and Documentation 4

Insurance Issues 5

Why the Insurance Companies “March to a Different Drummer” 5

Don’t Try to “Get Back” at the Insurance Company 5

The Insurance-Independent Practice 5

Coding and Explanations

The “F” Word (Fraud!) 6

The Importance of Using Current CDT codes 6

Using the Manual 6

A Simple Guide to Using this Manual to Search for a Given CDT Code 6

Deletions, New Procedures and Revisions for CDT-2011/2012 7

Legends 9

CDT-2011/2012 Codes with Explanations 10

Index 281

Error Correction Survey and “Cleaning Up” Your Coding

Error Correction Survey 321

Five Easy Steps to “Clean Up” Your Coding and Reduce Coding Errors 327

Acknowledgments 328

About the Author and Author’s Services 328

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123

6. Scalingandrootplaningisactivetherapy.Itisnotprophylactic(likeaprophy)orsupportive(likeD4910,whichisongoingandtherapeuticinnature).Scalingandrootplaningcanbedefinitive(finaltreatment)insomecases,orpre-surgical(priortoosseoussurgery)inothers.

7.Thereisnospecificcodeforirrigation.PayorstypicallyconsideritasintegraltoD4910.ContractedPPOdentistsmaybeprohibitedfromchargingaseparatefee.SeeD4999forcommentsregardingclinicaluseintheoffice.

8.Thereisacodetoreportapplicationofdesensitizingmedicaments,D9910.PayorstypicallyconsideritasintegraltoD4910.ContractedPPOdentistsmaybeprohibitedfromchargingaseparatefee.

D4355 full mouth DebriDement to enable comprehensive evaluation anD Diagnosis cDt-2011/2012

The gross removal of plaque and calculus that interfere with the ability of the dentist to perform acomprehensive oral evaluation. This preliminary procedure does not preclude the need for additionalprocedures.

1. Fullmouthdebridement(D4355)isonlytobeusedwherethecomprehensiveoralevaluation(D0150)orcomprehensiveperiodontalevaluation(D0180)cannotbeperformedduetoexcessiveandbulkycalculus,heavyplaque,anddebrisbuildup.AgeneralpracticewouldgenerallyuseD0150fortheroutinenewpatientcomprehensiveoralevaluation.However,ifthenewpatientshowssignsandsymptomsofperioorriskfactors,thenD0180maybereported.SeeD0180fordetails.

2. Thecomprehensiveoralevaluation(D0150/D0180)generallyfollowsthefullmouthdebridementonalaterdate(typicallyallowfourteendayshealing).Inthecaseofageneralpractice,D0150orD0180wouldfollow.Intheperiodontaloffice,D0180wouldgenerallyfollow.D4355isonlyreimbursedabout25-33%ofthetime,evenifsequencedperfectly.Thus,itisrejected67%-75%ofthetime,withperfectcodingsequence.

3. D4355isnotadefinitivetreatment.Itisonlypreliminaryinnature.Aprophylaxis(D1110),scalingandrootplaning(D4341/D4342),orreferraltoaperiodontist,alwaysfollowsthispreliminary procedure.

4. Donoterroneously reportD4355asa“firstvisitprophy”. Thispreliminaryprocedure is toenableacomprehensiveoralevaluation(D0150/D0180)andanalysis.Thepatientcouldbeperioornon-perio.

5. Ifthepatientcanbeadequatelydiagnosedwithboneloss,bleedingonprobing,and4mm-5mmorgreaterattachmentlossatthecomprehensiveoralevaluation,thenconsiderproceedingdirectlytoSRP,D4341/D4342.

6. ItiserroneoustoreportD4355followingperiodontalmaintenanceD4910,unlessthepatienthasbeenabsentfromthepracticesolongthattheoralevaluation(exam)uponreturncannotbeperformedduetoexcessivecalculusanddebris.D4910alwaysfollowsosseoussurgery(D4260/D4261)andgenerallyfollowsperiodontalscaling/rootplaning (D4341/D4342). SeeD4342forapossibleexceptionwhereprophylaxisfollowsSRPinverylimitedcircumstances.

7. Fullmouthdebridementisafullmouth,fourquadrantprocedure--notoneortwoquadrants.

1. Thesolepurposeoffullmouthdebridement(D4355)isforpreliminarydebridementofexcessiveandbulkycalculus to allow a proper periodontal and caries evaluation, which otherwise could not be performeddue to excessive plaque and calculus. This preliminary debridement is generally performed prior tothecomprehensiveoralevaluation (D0150)orcomprehensive periodontal evaluation (D0180).D0150orD0180 is not generally completed or charged out on the same service date, but on a subsequentdate.However, preliminary evaluation datamay begathered and recorded at the first visit. D4355 isnottypicallyreimbursedbypayorsonthesameservicedateasacomprehensiveoralevaluation(D0150)orcomprehensiveperiodontalevaluation (D0180/D0180).However,nothing in thedescriptorofD4355preventsacomprehensiveoralevaluation (D0150/D0180)onthesameservicedate - justdon’texpectreimbursement.

2. ProperdiagnosisandsequencingofD4355isveryimportantforreimbursement.Impropersequenceresults ineitherdenialor“remapping”toadifferentcode,usuallyprophylaxis (D1110). For instance,somepayorswilldowncodethefullmouthdebridement(D4355)toaprophylaxis(D1110);thenwhen

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D4355

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anotherD1110islatersubmitted,thepayorrefusestoreimburse,statingaprophylaxiswithinthetypical“onepersix-month”limitationperiodhaspreviouslybeenreimbursed.Furthermore,ifthecomprehensiveoralevaluation(D0150)orcomprehensiveperiodontalevaluation(D0180)isperformedpriortofullmouthdebridement,manypayorswillconvertD4355toaprophylaxis(D1110)forreimbursement,ifavailable.

3. IfD4355 is reimbursed, itmaybeclassifiedpreventive,basic,ormajor,butmostoftenclassifiedaspreventive.Planlimitationsarehighlyvariable.

4. Assuming a comprehensive oral evaluation (D0150/D0180) cannot be performed due to swelling,calculus,debris,andbleeding,thenafullmouthdebridementandfullseriesorpanographicdiagnosticfilms(optional)areperformedatvisit#1andthecomprehensiveoralevaluationiscompleted,andchargedout,includingathoroughperiodontalevaluationatvisit#2.Generally,followingfullmouthdebridement(D4355),fourteendaysmaybeallowedforhealingpriortothesubsequentcomprehensiveoralevaluation(D0150/D0180)servicedate;ahealingperiodisoftenarequirementforpayors.Generally,diagnosticfilms (panor full series)canbe takenat thefirst visit inconjunctionwith the fullmouthdebridement(D4355)withouthinderingthereimbursementofboth.

5. Planlimitationsregardingfrequencyoffullmouthdebridement(D4355)arehighlyvariable.Limitationsvaryfrom“onceperlifetime”toeverythreetofiveyears.

6. Somepayorswill reimburse fullmouthdebridement (D4355)onlywhen reportedasD4999. Othersmayreimburseonthebasisof,or“remapping”toPalliative(D9110).SeeTIPSbelowandalsorefertopalliative(D9110)forfurtherdetails.

7. Fullmouthdebridementtoenablecomprehensiveevaluationanddiagnosis(D4355)mayrequiremeetinganyassociateddeductible.

1. AnarrativeshouldbeusedwhenreportingD4355,forexample:“Patienthasnotseendentistinthreeyears.Afullmouthdebridementisnecessaryforasubsequentcomprehensiveoralevaluation”.Writeanarrativedescribingexcessiveandbulkycalculus,debris,bleeding,swelling,etc.,indicatingspecificallyhowthiswaspreventinganevaluation.Includephotographs.

2. Someofficesinforminsuredpatientsthattheyhavenotkeptuptheirpreventivevisits,andtwoprophylaxisvisitsarerequiredtobringtheirdentalhealthup-to-date.Sincetheyhaveprocrastinatedtwotothreeyearsforarecallvisit,insurancereimbursementforD1110islimitedto“onepersixmonths”or“twoperyear”,hencethe“overdue”patientispenalized.Thus,thepatientmustpayout-of-pocketforoneoftherequiredprophylaxis.Placetheburdenonthepatientforhis/herprocrastinationandlossofinsurancebenefitsandencourageroutinecare.

3. Undercurrentnomenclature,thereisnoalternateclassificationcodeforasecondprophyora“difficult”prophy. For the “difficult” prophylaxis requiring additional time, simply reportD1110 at a higher fee.However,PPOcontracteddentistswillfindthefeeforthe“extended”and“difficult”prophylaxiscapped.

Note:Thefullmouthdebridementcode(D4355)shouldnotberoutinelyusedonnewpatients.Thetypicalgeneraldentist’sofficewouldonlyusethiscodeafewtimesayear,asappropriate.

tip/narrative

D4355

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D4355

4. ProperSequenceforbestreimbursement:

5. Palliative (D9110) may possibly be reimbursed for partial mouth debridement under an acute andspontaneousdiscomfortscenario.Ifreimbursed,itgenerallyreimbursesatalowerUCRfeethanD4355.Theuseofthiscodemayworkfornon-PPOcontractedoffices,sincethepatientpaysanybalanceofthefee.SeeD9110forcomments.

Fourteendaywaitsuggestedforhealing

visit #1Fullmouthdebridement

(D4355)

plusIntraoral-completeseries

(D0210)(optionalatfirstvisit)

orPanographicfilm(D0330)

(optionalatfirstvisit)

Note:Atfirstvisit,preliminaryoralevaluationdatamaybegatheredbutnotreportedsincethecomprehensiveoralevaluation(D0150orD0180)isnotcomplete.

waiting period between visits

visit #2Comprehensiveoralevaluation

(D0150)orcomprehensiveoralperiodontalevaluation

(D0180)wouldbeperforated.

there are three possible scenarios upon the completion of the comprehensive oral evaluation at visit #2:

1.Aprophylaxis(D1110)isperformed.

2.Ifperiodontalproblemsexist,generallynoprophylaxisisperformed;fullydocumentandproceedtorootplaningandscaling(D4341/D4342)forapplicablequadrants.

3.Referraltoaperiodontisttotreatamorecomplexcase.

Note:Apanographicfilmonvisit#1andbitewingsatvisit#2(differentservicedate)mayresultinahigherreimbursementthantakenonthesameservicedate.SeeD0330.

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clinical flow chart

general practice scenario

Note:

1. Ifunabletoperformacomprehensiveoralevaluation(D0150/D0180)duetoexcessivebuildupofcalculusanddebris,proceedtoagrossdebridementtoenablecomprehensiveoralevaluation(D4355).

2. Necessarydiagnosticfilmsmaybetakenoneither/bothgrossdebridement(D4355)orcomprehensiveoralevaluation(D0150/D0180)servicedates.For instance,apanographicfilm(D0330)onthegrossdebridement(D4355)servicedateandfourbitewings(D0274)onthesubsequentcomprehensiveoralevaluation(D0150/D0180)datemayavoid“remapping”ordowncodingtoacompleteseries(D0120),UCRfee.

3. Thecomprehensiveoralevaluation(D0150orD0180)shouldfollowgrossdebridement(D4355)onasubsequentservicedate,withasuggestedintervaloffourteendaysormoreforhealing.ReimbursementforD4355isonlyavailableabout25%–30%ofthetime,soinformthepatientofpatientresponsibilityforout-of-pocket.SeealsopalliativeD9110asapossiblealternativeifthepatienthasdiscomfort.

D4381 localizeD Delivery of antimicrobial agents via a controlleD release vehicle into DiseaseD crevicular tissue, per tooth, by report cDt-2011/2012

FDAapprovedsubgingivaldeliverydevicescontainingantimicrobialmedication(s)areinsertedintoperiodontalpocketstosuppressthepathogenicmicrobiota.Thesedevicesslowlyreleasethepharmacologicalagentssotheycanremainattheintendedsiteofactioninatherapeuticconcentrationforasufficientlengthoftime.

Prophylaxis(D1110)

Scalingandrootplaning

(D4341/D4342)

RefertoPeriodontist

NewPatient

Grossdebridementtoenablecomprehensiveevaluationanddiagnosis(D4355)

Comprehensiveoralevaluation(D0150orD0180)

Andeither:

Abletoperformevaluation

Unab

leto

per

formevaluation

14days

D4381

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D5213 maxillary partial Denture - cast metal framework with resin Denture bases (incluDing any conventional clasps, rests anD teeth) cDt-2011/2012

1. For adjustment of a cast framework maxillary partial denture, see D5421.

2. For repair of cast framework partial denture base, see D5610.

3. For repair of cast framework for a cast framework partial, see D5620.

4. For repair or replace broken clasp, see D5630.

5. For replacement of missing or broken teeth (each tooth), see D5640.

6. For adding tooth to existing cast framework partial denture, see D5650.

7. For adding clasp to existing cast framework partial denture, see D5660.

8. For rebase of cast framework maxillary partial denture, see D5720.

9. For chairside reline of cast framework maxillary partial denture, see D5740.

10. For lab (processed) reline of cast framework maxillary partial denture, see D5760.

11. For replacing all teeth and acrylic on a cast framework maxillary partial denture see D5670.

1. Maxillary partial denture (D5213) includes a partial with a cast metal framework.

2. D5213 may be excluded if patient is under a certain age (twelve to sixteen), depending on the payor.

3. Diagnostic casts (D0470) are included in the global fee for a maxillary partial denture (D5213).

4. Follow-up adjustments during the succeeding six months are also typically included in the global fee, and thus not reimbursed separately. An adjustment by a different office may be reimbursed in less than six months.

5. Generally, there is a five to ten year exclusion period for a replacement partial denture, plus proof the prosthesis cannot be made serviceable.

6. For a precision partial, also report a precision attachment, D5862 for each attachment.

If flexible Valplast® or Proplast®-type clasps are used in conjunction with a maxillary cast metal framework, report D5213.

This is an example of a maxillary partial denture with a cast metal framework.

Courtesy Drake Dental Lab

D5214 manDibular partial Denture - cast metal framework with resin Denture bases (incluDing any conventional clasps, rests anD teeth) cDt-2011/2012

1. For adjustment of a cast framework mandibular partial denture, see D5422.

2. For repair of cast framework partial denture base, see D5610.

3. For repair of cast framework for a cast framework partial, see D5620.

4. For repair or replace broken clasp, see D5630.

5. For replacement of missing or broken teeth (each tooth), see D5640.

6. For adding tooth to existing cast framework partial denture, see D5650.

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INDEX

A Code PageAbscess, incision and drainage, all types D7510-D7521 236-237

Abutments

Custom abutment (implant) - includes placement D6057 169

Locator abutment (implants) - includes placement D6056 or D5862 168/155

Place abutment (previously deleted) D6020 (previously deleted) 167

Prefabricated abutment (implant) - includes placement D6056 168

Retainers (bridgework) D6545-D6795 195-212

Retainers for resin bonded “Maryland Bridge” D6545/D6548 195/196

Retainers (implant/abutment supported bridgework) D6068-D6074; D6194 179-181/187

Accession of tissue D0472-D0486 35-38

Access closure (after endodontic treatment)

Crown repair (endodontic access closure) D2980 90

Crown retainer repair (endodontic access closure) D6980 217

Direct restoration (endodontic access closure) D2140/D2330/D2391 49/52/56

Accident

Avulsed tooth D7270/D7670 224/238

Displaced tooth D7270/D7670 224/238

Evulsed tooth D7270/D7670 224/238

Palliative (emergency) treatment (minor procedure) D9110261 261

Problem focused evaluation (exam) D0140 (could be emergency-related) 11

Re-evaluation (follow-up) limited evaluation D0170 (could follow D0120/D0140/D0150/D0180) 16

Suture lip/other (small wound) D7910-D7912 243-244

Acid etch, integral to direct resin procedure No separate code

Acrylic hard splint

Occlusal guard (bruxism/clenching diagnosis) D9940 274

Occlusal orthotic device (TMJ diagnosis) D7880 242

Acrylic (resin) partial (long-lasting, not temporary) D5211/D5212 136/137

Acrylic (resin) partial (temporary flipper) D5820/D5821 152/153

Acute pain relief

Palliative (emergency) treatment (minor procedure) D9110 261

Problem focused (emergency) evaluation (exam) D0140 11

Pulpal debridement (open prior to endodontic treatment visit) D3221 93

Pulpotomy (primary tooth generally) D3220 92

Sedative filling now termed “protective restoration” D2940 83Also see Palliative (D9110)

Adhesives, bonding agents No separate code

Adjunctive General Services D9000-D9999 261-280

Adjunctive pre-diagnostic test (cancer screening) ViziLite®/VELscope™/Microlux DL, Identafi® 3000 D0431 33

INDEX

A

14 Dental Explorer | Second Quarter 2011

Dental Explorer | Second Quarter 2011 15

To order:please call 800.218.5412 or contact your Atlanta Dental Representative

0825CWC Coding with Confidence......$10995

Dramatically Cut Coding Errors

and Boost Legitimate

Reimbursement

Charles Blair, D.D.S.

CODING WITH CONFIDENCE:THE “GO TO” DENTAL INSURANCE GUIDE

CDT-2011/2012 EDITION

PLUS

Illustrations

and Error

Correction

Survey

Book sampler:

These are sample pages of the book containing front and back cover, table of contents,

explanation of legends, sample full mouth debridement (D4355) code, and index