Dental Billing and Coding 101
Billing and Coding for the dental practice continues to advance and involve the medical carrier with obtaining
payment for certain procedures. Dentists are beginning to realize how beneficial a certified professional is to managing the billing side of their practice. With that said, the need for certified professionals educated in the following specialties are in demand; Oral and Maxillofacial Surgery, Periodontics, Endodontics, Orthodontics, and General Dentists who specialize in sleep apnea.
While I could write a novel on the idiosyncrasies of dental billing and coding, for the purpose of this article I will explore the basics.
What is a Dental code and where do I find it?
Dental codes are commonly referred to as CDT-5 codes (Current Dental Terminology, Fifth Edition). These codes were developed by the counsel on Dental Benefit Programs and published by the ADA (American Dental Association). When first creating these codes the council worked closely with dental office staff, claims reviewers, and third-party payers to create and publish CDT-1 beginning in 1991. Since then they have adapted and modified four revisions with CDT-5 as the newest addition beginning in 2006.
The CDT code has been designated as the national standard for reporting dental services by the Federal Government under HIPAA and is currently recognized by third party payers nationwide. These codes are currently maintained by the CRC (Code Revision Committee) which was formed in 2001. This committee is comprised of representatives from the BCBSA (Blue Cross Blue Shield Association), CMS (Center for Medicare and Medicaid Services), HIAA (Health Insurance Association of America), DDPA (Delta Dental Plans Association), and the ADA’s Council on Dental Benefit Programs (CDBP).
Dental Procedure Codes are located in both the HCPCS Level II book published by Ingenix and the CDT-5 book published by the ADA. CDT codes are five character alphanumeric codes beginning with the letter “D” followed by 4 numbers. These codes are largely self explanatory; however here is an example of a dental code and descriptor: D7230 – Extraction of a partially bony impacted wisdom tooth.
Every payer/insurance carrier has their own guidelines as to how or if they will cover certain dental expenses. It is always a good idea to obtain a pre-authorization or pre-certification from the dental and/or medical carrier before proceeding with a procedure.
Many carriers also have a coordination of benefits clause. This clause generally states; if the dental carrier pays any portion of the procedure the medical carrier will not be liable and vice versa. In instances where no coordination of benefits clause exists you can maximize reimbursement and minimize the patients out-of-pocket expense by billing both the medical and dental carrier for payment. Please note, you are not allowed to collect more than the allowed fee from both carriers combined.
So who gets billed first the medical or dental carrier? It has been my experience to bill the dental carrier first unless I know for certain the expense will be paid by the medical carrier. For example, it is now common practice for medical carriers to pay for impacted wisdom teeth, alveoloplasty, gingivectomy/gingivoplasty, subepithelial tissue grafts, and osseous surgery.
What to do when the medical carrier should be involved.
First you must determine if the dental code you intend to use has a compatible medical code. Since not all dental codes (CDT) have a compatible medical code (CPT), proper coding guidelines are to use the CDT “D” code for submission if no CPT code exists.
The best way to determine if the CDT code has a compatible medical code is to cross reference with the CPT book. Additionally, the HCPCS Level II book, published by Ingenix, has compatible CPT codes next to the appropriate “D” code. I suggest you verify the cross reference as I have found some inaccuracies.
Here are a few examples of CDT codes that have a compatible CPT code.
Description CDT code CPT code
- Alveoloplasty w/ extractions per quadrant D7310 41874
- I & D of abscess – intraoral soft tissue D7510 41800
- Biopsy of oral tissue – soft D7286 40808
- Osseous surgery 1-3 teeth/spaces per quadrant D4261 41823
- Panoramic film D0330 70320
Now you have to determine the proper form to use for submission. When submitting a dental claim to the medical carrier you must use a CMS-1500 form (formerly HCFA-1500) instead of the commonly used dental ADA form. Since there is no tooth or quadrant box located on the CMS-1500 form you will use box 24D (area marked modifier field) for teeth numbers or quadrants involved for the particular procedure code being used. It is a good idea to include a copy of the denied EOB (explanation of benefits) or request for primary carrier denial from the dental carrier along with your claim.
Below is an example of a common procedure that would involve the patients medical and dental insurance and how to bill it.
Gina is a 16 year old female that presents with four full bony impacted wisdom teeth. Doctor takes a panoramic x-ray and does a detailed exam. Gina is then scheduled for a 45 minute surgery for the removal of impacted wisdom teeth with IV conscious sedation two weeks later.
First visit the office will bill the following codes to the dental carrier
D0160 – Detailed exam
D0330 – panoramic film
Second visit the office will bill the following codes to the medical carrier
D7240 -1 Full bony impacted wisdom tooth removal
D7240 -16 Full bony impacted wisdom tooth removal
D7240 -17 Full bony impacted wisdom tooth removal
D7240 -32 Full bony impacted wisdom tooth removal
D9241 IV conscious sedation first 30 minutes
D9242 IV conscious sedation ea add 15 minutes
The first visit with the exam and x-ray would be submitted to the patients dental carrier. Typically the medical carrier will not cover this stating “this dental expense is not a covered benefit.”
The second visit will be submitted to the medical carrier first as the dental carrier will typically ask for “the primary plan or medical plans denial of benefits”. If the procedure is not covered by the medical carrier you would then submit a claim to the dental carrier with a copy of the denial from the medical carrier.
The example above is the most common billing and coding problem that currently plagues the dental practice. Some additional areas would include; appeals process, coding surgical procedures, understanding an EOB, credentialing with medical carriers, and much more.
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