May 2017 Volume LII Number 3

 
 
 
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Coding Corner

May 2017 Volume LII Number 3

CDT 2017 – New Codes for Pediatric Dentistry Include Four Case Management Codes

The Code on Dental Procedures and Nomenclature (CDT) is updated annually. The American Dental Association (ADA)’s Code Mainte- nance Committee (CMC) meets early each year to review the code change requests that are submitted, and votes to either accept, deny or table each request. For 2017, the CMC adopted 17 substantive changes and 40 editorial changes. The substantive changes consist of 11 new codes, five revised codes and one deleted code. This article will review the new codes pertinent to pediatric dentists. Of particular note is recognition of four case management codes which were submitted by the AAPD.

D0414 Laboratory processing of microbial specimen to include culture and sensitivity studies, preparation and transmission of written report

Rationale for adding D0414:
In the past, CDT contained a code to report the col- lection of a specimen. However, there has not been a specific code for reporting the laboratory processing of a microbial speci- men, including culture and sensitivity studies, preparation of the sample, and transmission of a written report. This process had to be reported by an unspecified, "by report" code. CDT 2017 creates D0414 to report the labo- ratory processing of a microbial specimen.

D0600 Non-ionizing diagnostic procedure capable of quantifying, monitoring, and recording changes in structure of enamel, dentin, and cementum

Rationale for adding D0600: Nonionizing "light" is a relatively new technology used to quantify, monitor, and record changes in tooth structure (i.e., enamel, dentin, and ce- mentum). This technology uses transillumina- tion to highlight areas of potential caries and cracks by capturing an image of the diseased tooth. Non-ionizing light produces an image where enamel appears transparent and cari- ous lesions and cracks are dark.

One of the most popular products on the market providing this transillumination technology is the DEXIS CariVuTM caries detection device.

D1575 Distal shoe space maintainer – fixed – unilateral


Fabrication and delivery of fixed appli- ance extending subgingivally and distally to guide the eruption of the first permanent molar. Does not include ongoing follow-up or adjustments, or replacement appliances, once the tooth has erupted.

Rationale for adding D1575: A distal shoe space maintainer is utilized following the premature loss or extraction of a primary second molar to guide the unerupted, perma- nent first molar into the proper arch position. These space maintaining appliances may be placed immediately following the extrac- tion of the primary second molar or at a subsequent appointment. This type of fixed space maintainer extends subgingivally and distally to guide the proper eruption of the first permanent molar.

For example, a pediatric patient requires the extraction of the lower left second primary molar. A unilateral, fixed distal shoe space maintainer is attached to the remain- ing first primary molar. This specific type of space maintainer helps promote the proper eruption of the first permanent molar.

The submitter suggested that the existing code D1510, space maintainer – fixed – uni- lateral, does not accurately describe a distal shoe space maintainer that extends subgin- givally and distally to guide the eruption of the first permanent molar. Therefore, a distal shoe fixed appliance should not be reported using any of the existing space maintainer codes. The CMC agreed with this stance and acknowledged the need for a new code to de- scribe the fixed distal shoe space maintainer.

D4346 Scaling in presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation

The removal of plaque, calculus and stains from supra- and subgingival tooth surfaces when there is generalized moder- ate or severe gingival inflammation in the absence of periodontitis. It is indicated for patients who have swollen, inflamed gingiva, generalized suprabony pockets, and moder- ate to severe bleeding on probing. Should not be reported in conjunction with prophylaxis, scaling and root planing, or debridement procedures.

Rationale for adding D4346: Perhaps one of the biggest debates in the dental coding arena concerns treatments that are more complex than a typical prophylaxis, but do not qualify as periodontal treatment or even full mouth debridement. In order to qualify for scaling and root planing (SRP), D4341 or D4342, the patient must have radiographic evidence of bone loss, pocket depths of 4mm or more, and bleeding on probing, indicating active periodontal disease. Additionally, full mouth debridement (D4355) is justified when an oral evaluation cannot be performed due to excessive calculus, heavy plaque, and debris buildup.

When a patient presents with moderate or severe gingival inflammation but no bone loss (and an oral evaluation can be success- fully performed) the time and effort needed to treat the condition are often well beyond a standard prophylaxis. However, reporting either SRP or gross debridement is consid- ered inappropriate, since the patient (with gingivitis) typically does not have all of the signs and symptoms required to report either of these codes. Thus, there is no existing code that accurately reports the additional time and effort required to treat the patient’s mod- erate or severe gingival inflammation.

Following a work group’s (including the AAPD CMC representative) research and considerable debate, a consensus on the proper code to report was reached. And thus, D4346, scaling in the presence of moderate or severe gingival inflammation, was created. The work group indicated that the patient’s inflammatory condition may be chronic or acute, but also stressed that there are very specific diagnostic criteria for the submission of moderate or severe gingival inflammation (gingivitis). The payers hope that by add- ing new code D4346, the frequent abuse or upcoding of the existing SRP codes (D4341 or D4342) will decrease.

D4346’s descriptor clearly indicates that this code should not be submitted with D1110 (prophylaxis, adult), D4341 and D4342 (scaling and root planing), or D4355 (full mouth debridement) when performed on the same service date. In nearly every case, with appropriate treatment and im- proved hygiene, moderate or severe gingival inflammation is a reversible condition so the subsequent treatment visit (typically two to four weeks later) could be described using the conventional prophylaxis code, D1110. Typically, the patient is then placed on a six month recall schedule.

D9311 Consultation with a medical health care professional

Treating dentist consults with a medical health care professional concerning medical issues that may affect patient’s planned dental treatment.

Rationale for adding D9311: In order to offer a patient with contributory health condi- tions the best treatment options, the treating dentist may need to consult with the patient’s other health care professionals. The purpose of this consultation is to discuss a proposed or active treatment and ensure that the appro- priate care is provided while also being mind- ful of other potentially dangerous medical conditions. The patient does not need to be a part of this exchange of information between the various medical providers.

D9991 Dental case management – addressing appointment compliance barriers

Individualized efforts to assist a patient to maintain scheduled appointments by solving transportation challenges or other barriers.

D9992 Dental case management – care coordination

Assisting in a patient’s decisions regard- ing the coordination of oral health care services across multiple providers, provider types, specialty areas of treatment, health care settings, health care organizations and payment systems. This is the additional time and resources expended to provide experi- ence or expertise beyond that possessed by the patient.

D9993 Dental case management – motivational interviewing

Patient-centered, personalized counseling using methods such as Motivational Inter- viewing (MI) to identify and modify behaviors interfering with positive oral health outcomes. This is a separate service from traditional nutritional or tobacco counseling.

D9994 Dental case management – patient education to improve oral health literacy


Individual, customized communication of information to assist the patient in making appropriate health decisions designed to im- prove oral health literacy, explained in a man- ner acknowledging economic circumstances and different cultural beliefs, values, attitudes, traditions and language preferences, and adopting information and services to these differences, which requires the expenditure of time and resources beyond that of an oral evaluation or case presentation.

Rationale for adding D9991, D9992, D9993, and D9994: The American Academy of Pe- diatric Dentistry (AAPD) submitted a request for the addition of case management codes to provide a method to quantify case manage- ment efforts. Additionally, California has a Medicaid-Dental Transformation Initiative, and California Medicaid provides incen- tives for dental health management efforts. Each of these federally supported initiatives involves certain documentation requirements.

With all of these case management initia- tives in place, case management codes are necessary to help dentists report any efforts to fulfill the documentation requirements of the initiatives.

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

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