March 2019 Volume LIV Number 2

 
 
 
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Behind the Code

March 2012 Volume XLVIII Number 2

Code Revision Committee

For the past 10 years, the Code Revision Committee (CRC) has been in charge of maintaining the American Dental Association’s Code on Dental Procedures and Nomenclature, also referred to as The Code or CDT. These are the dental codes we use every day to submit insurance claims, record procedures for our own individual use, and communicate to other members of the dental community the procedures that have been performed. As of December 2011, the CRC is defunct. The ADA notified the insurance industry about this change in late September 2011.

Background
The CRC was initially created as part of a legal settlement between the ADA and corporate members of Delta Dental Insurance Company. The initial phase of the agreement was for ten years. When the ten-year contract expired, the two sides met to renew the agreement but could not come to terms that were acceptable to both parties. In the meantime, the ADA has developed the Code Advisory Committee (CAC) whereby they have invited the following organizations to name a representative to participate as an advisor to the CAC.

  • Five current or past members of the ADA Council on Dental Benefit Programs

  • One representative from each of the nine recognized dental specialty organizations

    Academy of Prosthodontics

    American Academy of Oral and Maxillofacial Pathology

    American Academy of Oral and Maxillofacial Radiology

    American Academy of Pediatric Dentistry

    American Academy of Periodontology

    American Association of Endodontists

    American Association of Oral and Maxillofacial Surgeons

    American Association of Orthodontists

    American Association of Public Health Dentistry

  • One representative from the Academy of General Dentistry

  • One representative from each of the following third-party payer organizations a. America’s Health Insurance Plans

  • Blue Cross and Blue Shield Association

  • Centers for Medicare and Medicaid Services

  • Delta Dental Plans Association

  • National Association of Dental Plans

  • One representative from the American Dental Education Association

CAC members will be asked to review and provide advisory comments on requested changes to the CDT Code. This advice will be considered by the CDBP as it makes the decision to accept or decline a request to add, revise, or delete a CDT Code entry. The CAC is scheduled to meet at ADA Headquarters in Chicago on Feb. 10-11, 2012.

For the past decade, the ADA has owned the copyright to the CDT codes but has only been represented by half of the voting members of the CRC. The other half of the CRC represented third-party payers. These included representatives from Delta Dental, Blue Cross Blue Shield, National Association of Dental Plans, America’s Health Insurance Plans, the Centers for Medicare & Medicaid Services (CMS), and a single Plan Purchaser. The composition of the now defunct CRC and the unique rules that were created by the settlement agreement made it challenging to make changes to CDT.

What Next?
The inability of CDT to quickly adapt to the needs of dentists has been a source of frustration in dental offices around the country for many years. New procedures are often not reflected in CDT until long after they have been accepted into general use. Without voting representatives of insurance companies applying the brakes, it is speculated that the new CAC revision process will accelerate considerably despite some carriers’ concerns that the code revision process may now accelerate too fast for carriers to adjust payment schedules. The AAPD is currently in discussions with the ADA to convince them that the newly created CAC should offer voting privileges to the dental specialty organizations for overall decisions to accept, revise or reject procedure code proposals.

For more information, please contact AAPD Dental Benefits Manager Mary Essling at (312) 337-2169 or messling@aapd.org.

MARK YOUR CALENDAR!

Insurance Symposium - Friday, May 25, 2012

Strategies for Avoiding or Surviving an Audit

The CBDP has assembled a panel of experts to present their experiences in the current insurance environment, reimbursement challenges along the way and what practice management skills must be adhered to in order to remain compliant and avoid the pitfalls of an insurance audit (especially under the Medicaid program).

Panelists include:

Dr. Gene McGuire, former AAPD District II Trustee who was audited and wrongfully accused of performing too many stainless steel crowns in the OR, among other accusations. McGuire will share his Medicaid Audit experience and the strategies that won his appeal to CMS.

Representative from Strategic Health Solutions (SHS), LLC. SHS works with CMS as an Education Medicaid Integrity Contractor (EMIC). The EMIC is tasked with promoting the integrity of the Medicaid program by educating providers of services, managed care entities, Medicaid beneficiaries and other individuals regarding program integrity and quality of care. The EMIC has undertaken a national initiative to provide training and education materials to fight fraud, waste, and abuse within the Medicaid programs, to educate stakeholders about appropriate and accurate billings for services under the Medicaid program, and to inform those providing and receiving Medicaid services about quality of care issues affecting Medicaid beneficiaries. They will discuss:

  • The overall program integrity landscape, including a brief description of the entities involved, their focus, and scope of work.

  • The benefits of a compliance program.

  • The overall objectives for a compliance program, its basic elements, and how to facilitate compliance at the practice level.

  • What documentation of medical necessity means in the dental world.

  • Good documentation expectations, the scope and definition of medical necessity in dentistry, the documentation of consent and quality of care, and using dental software as a tool for good documentation practice.

  • Assessing and maintaining the integrity of a practice.

  • How to safeguard information and routine monitoring, with suggestions for what to do when problems are discovered.

Dr. Paul Reggiardo, CDBP chair, will update attendees on Council activities related to audits. Dr. Sidney Whitman, chair of the ADA’s Medicaid Provider Advisory Committee (MPAC), will give a report on National Medicaid activities.

For more information, please contact AAPD Dental Benefits Manager Mary Essling at (312) 337-2169 or messling@aapd.org.