AAP Guidelines

CURRENT PROCEDURAL TERMINOLOGY FOR PERIODONTICS AND INSURANCE REPORTING MANUAL

13th EDITION

A glossary of terms and procedures designed as a guide for interpreting and reporting periodontal services to third party agencies.

Published by the American Academy of Periodontology

Copyright January 2011 by The American Academy of Periodontology

737 North Michigan Avenue, Suite 800 Chicago, IL 60611-6660

All rights reserved.

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means,

electronic, mechanical, photocopying, or otherwise without written permission of the publisher.

PREFACE This online publication represents a collection and standardization of procedures and terms currently in use in periodontics. It is designed to facilitate the reporting of periodontal services provided to patients by the dentist to any third party. Periodic revisions of this online publication will be provided at the discretion of the American Academy of Periodontology. Inquiries should be directed to: Patient Benefits and Advocacy Advisory Committee The American Academy of Periodontology 737 North Michigan Avenue Suite 800 Chicago, IL 60611-6660 Phone: 312/573-3241 or 800/282-4867 ext. 3241 Fax: 312/573-3234 Web Site: www.perio.org E-mail: [email protected]

Current Procedural Terminology for Periodontics and Insurance Reporting (CPT-13) of 66

Acknowledgments This 13th edition of Current Procedural Terminology for Periodontics and Insurance Reporting Manual (CPT-13) represents a culmination of efforts of the Patient Benefits and Advocacy Advisory Committee of the American Academy of Periodontology. Dr. S. Jerome Zackin, Committee chair, and comprised of Drs. Allan H. Charles, Donald E. Janoff, Joel Jaspan, Richard B. Kaplan, Peter M. Loomer, Marie C. Schweinebraten; Board Liaisons James B. Barnes and John P. Ducar. Throughout this resource you will find links to Academy resources, policy statements, position papers, parameters of care and other relevant information. Some of this information is available only to members, and as such, you may need to use your Academy member login and password to access some of the information. PATIENT BENEFITS AND ADVOCACY ADVISORY COMMITTEE The charge of the Patient Benefits and Advocacy Advisory Committee (PBAAC) is to: Provide input and advice on matters related to third party reimbursement for periodontal diagnosis and treatment.

• Assist members in resolving reimbursement problems. • Recommend adoption of appropriate codes to benefit periodontal diagnosis and treatment. • Correspond and meet with dental directors, consultants, benefit purchasers, dental plan designers

and others to advocate benefits for patients’ periodontal treatment. The PBAAC, and other committees prior, have developed a variety of statements on dental prepayment for use by Academy members and third party carriers. Many can be found in this publication. They also are available in the Members Only section of the Academy’s Web site, www.perio.org, and from the Academy’s Central Office. Communication with members on third party issues is maintained through Periospectives (the AAP Newsletter), the AAP Web site, and by direct contact with the Academy’s Clinical Affairs Manager and Insurance Consultant. The PBAAC offers regularly updated insurance workshops at the Annual Meeting and at state and regional periodontal society meetings upon request. These workshops provide information to Academy members, non-member dentists, and third parties on proper reporting of periodontal services. Please contact the Academy’s Clinical Affairs Manager at 312/573-3241 for more information. The Academy’s Clinical Affairs Manager and Insurance Consultant provide members, carriers, and purchasers of dental plans with counsel on matters related to the field of periodontics. They offer advice to members on dental benefits and represent members with third parties to resolve problems related to the provision and reporting of periodontal treatment. In addition, members of the Academy are able to draw upon the Committee when opportunities arise to influence plan design, particularly with purchasers of benefit plans. Through active liaison with the American Dental Association Council on Dental Benefit Programs, the American Association of Dental Consultants, and a number of third party carriers, the Committee and the Academy are better prepared to impact the benefits industry through participation in conferences and the Code on Dental Procedures and Nomenclature revision process.


Table of Contents Section 1 Classification System for Periodontal Diseases and Conditions................................. 5

Section 2 Statements of the American Academy of Periodontology Regarding Dental Health Plans as Related to Periodontics................................................................................................ 11

Section 3 Description of Selected Procedural Codes ........................................................................ 19

Section 4 Insurance Reporting ................................................................................................................. 35 Submitting a Claim Form ......................................................................................................................................... 35 Dentist’s Pretreatment Estimate .......................................................................................................................... 36 Transactions and Code Sets.................................................................................................................................... 38 National Provider Identifier (NPI) ....................................................................................................................... 38 Dental Claim Examples ............................................................................................................................................. 39 Emergency Visit........................................................................................................................................................... 39 Supplemental Examples ........................................................................................................................................... 40 Failing Implant ............................................................................................................................................................ 40 Multiple Treatment Needs ....................................................................................................................................... 40 Extraction to be Followed by Single tooth Implant ....................................................................................... 40 Connective Tissue and Free Gingival Grafts ..................................................................................................... 40 Clinical Crown Lengthening – Hard Tissue........................................................................................................ 40 Cone Beam CT .............................................................................................................................................................. 41 Ridge Augmentation.................................................................................................................................................. 41 Predetermination of Benefits ................................................................................................................................. 41 HIPAA’s Impact on Dentistry ................................................................................................................................. 42 Use of Medical Codes................................................................................................................................................. 46

Section 5 Medicare ........................................................................................................................................ 55 Medicare Participation.............................................................................................................................................. 56 Medicare Resources ................................................................................................................................................... 57

Section 7 AAP Insurance Policy Statements........................................................................................ 65

Section 8 NDEDIC Glossary of Dental Benefit Plans and Related Terminology ..................... 65

Section 9 AAP Frequently Asked Questions ......................................................................................... 66


Section 1 Classification System for Periodontal Diseases and Conditions* Classification systems are necessary in order to provide a framework in which to scientifically study the etiology, pathogenesis, and treatment of diseases in an orderly fashion. In addition, such systems give clinicians a way in which to organize the health care needs of their patients. In 1989, scientists and clinicians met at the World Workshop in Clinical Periodontics, and agreed upon a classification system for periodontal disease.1 Subsequently, a simpler classification was agreed upon at the 1st European Workshop in Periodontology held in 1993.2 These classification systems have been widely used throughout the world. Unfortunately, the 1989 classification had many shortcomings including: 1) considerable overlap in disease categories; 2) absence of a gingival disease component; 3) inappropriate emphasis on age of onset of disease and rates of progression; and 4) inadequate or unclear classification criteria. The 1993 European classification lacked the detail necessary for adequate characterization of the broad spectrum of periodontal diseases encountered in clinical practice. The need for a revised classification system was emphasized during the 1996 World Workshop in periodontics.3 In the fall of 1999, the American Academy of Periodontology hosted the International Workshop for a Classification of Periodontal Diseases and Conditions. As a result of this workshop, a new classification system was agreed upon, and is provided in Figure 1. The highlights of this new classification system include: 1. The addition of a section on “Gingival Diseases.” An important feature of the section on dental

plaque-induced diseases is an acknowledgment that the clinical expression of gingivitis can be substantially modified by 1) systemic factors such as disorders of the endocrine system, 2) medications, and 3) malnutrition. The section on non-plaque- induced gingival lesions includes a wide range of disorders that affect the gingiva. Many of these disorders are frequently encountered in clinical practice.

2. The replacement of “Adult Periodontitis” with “Chronic Periodontitis.” From the outset, the

term “Adult Periodontitis” has created a diagnostic dilemma for clinicians. Epidemiological data and clinical experience suggest that this form of periodontitis can also be seen in adolescents.4 If this is true, how can non-adults (e.g., adolescents) with this type of periodontal disease be said to have “adult periodontitis?” Clearly, the age-dependent nature of the adult periodontitis designation created problems. Therefore, the more generalized term “Chronic Periodontitis” is used to characterize this constellation of destructive periodontal diseases. Traditionally, this form of periodontitis has been characterized as a slowly progressive disease.5 However, there also are data indicating that some patients may experience short periods of rapid progression.6, 7 Therefore, rates of progression should not be used to exclude patients from receiving the diagnosis of Chronic Periodontitis. It can, however, be further classified on the basis of extent (localized or generalized) and severity (slight, moderate, or severe).

3. The replacement of “Early-Onset Periodontitis” with “Aggressive Periodontitis.” A diagnosis

of “Early-Onset Periodontitis” (EOP) implies temporal knowledge of when the disease started, yet in clinical practice and most other situations that rarely is the case. Also, there is considerable uncertainty about an arbitrary upper age limit. Accordingly, the term “Aggressive Periodontitis” was adopted. It, too, may be further classified on the basis of extent and severity.


4. The elimination of a separate disease category for “Refractory Periodontitis.” A small percentage of patients with all forms of periodontal disease experience a continuing progression of periodontitis in spite of excellent patient compliance and the provision of periodontal therapy that succeeds in most patients. Because of the diversity of clinical conditions and treatments under which periodontal therapy fails to arrest the progression of periodontitis, it was determined that “Refractory Periodontitis” is not a single disease entity.

5. The clarification of the designation “Periodontitis as a Manifestation of Systemic

Diseases.” Since it is clear that destructive periodontal disease can be a manifestation of certain systemic diseases, the classification of “Periodontitis as a Manifestation of Systemic Diseases” has been retained. However, diabetes mellitus is not on that list. While it can alter the clinical course and expression of chronic and aggressive forms of periodontitis, there are insufficient data to conclude that there is a specific diabetes mellitus-associated form of the disease.

6. Replacement of “Necrotizing Ulcerative Periodontitis” with “Necrotizing Periodontal

Diseases.” Periodontitis associated with ulcerative gingivitis (NUG) and necrotizing ulcerative periodontitis (NUP) are clinically identifiable conditions, but the relationship between them is uncertain. It is not known whether they are a single disease process or truly separate diseases. Accordingly, both clinical conditions were placed under the single category of “Necrotizing Periodontal Diseases.”

7. The addition of a category on “Periodontal Abscess.” Since periodontal abscesses present special diagnostic and treatment challenges, a simple classification was adopted, based primarily on location (i.e., gingival, periodontal, pericoronal).

8. The addition of a category on “Periodontic-Endodontic Lesions.” The 1989 classification did

not include a section on the connection between periodontitis and endodontic lesions. Therefore, a simple classification based on this connection, not on initial etiology, has been added.

9. The addition of a category on “Developmental or Acquired Deformities and Conditions.”

Developmental and acquired deformities and conditions often are important modifiers of the susceptibility to periodontal diseases or can dramatically influence outcomes of treatment. Since periodontists are routinely called upon to treat many of these conditions, they have been given a place in the new classification.

As more is learned about the etiology and pathogenesis of periodontal diseases, future revisions to this classification will be needed. All classifications have inconsistencies or inaccuracies and the present system is no exception. Nevertheless, it represents the consensus of an international group of experts and is intended to be useful to the profession and the public it serves. References 1. The American Academy of Periodontology. Proceedings of the World Workshop in Clinical Periodontics.

Chicago: The American Academy of Periodontology; 1989: I/23-I/24. 2. Attström R, van der Velden U. Consensus report (epi-demiology). In: Lang NP, Karring T, eds.

Proceedings of the 1st European Workshop on Periodontics, 1993. London: Quintessence; 1994; 120-126.

3. Armitage GC. Periodontal diseases: Diagnosis. Ann Periodontol 1996; 1:37-215. 4. Papapanou PN. Periodontal diseases: Epidemiology. Ann Periodontol 1996; 1:1-36. 5. Brown LJ, Löe H. Prevalence, extent, severity and pro-gression of periodontal disease. Periodontol

2000 1993; 2:57- 71.


6. Socransky SS, Haffajee AD, Goodson JM, Lindhe J. New concepts of destructive periodontal disease. J Clin Periodontol 1984; 11:21-32.

7. Jeffcoat MK, Reddy MS. Progression of probing attachment loss in adult periodontitis. J Periodontol 1991; 62:185-189.

*Adapted from Armitage GC. Development of a classification system for periodontal diseases and conditions. Ann Periodontol 1999; 4:1-6. I. Gingival Diseases A. Dental plaque-induced gingival diseases* 1. Gingivitis associated with dental plaque only a. without other local contributing factors b. with local contributing factors (See VIII A) 2. Gingival diseases modified by systemic factors a. associated with the endocrine system 1) puberty-associated gingivitis 2) menstrual cycle-associated gingivitis 3) pregnancy-associated a) gingivitis b) pyogenic granuloma 4) diabetes mellitus-associated gingivitis b. associated with blood dyscrasias 1) leukemia-associated gingivitis 2) other 3. Gingival diseases modified by medications a. drug-influenced gingival diseases 1) drug-influenced gingival enlargements 2) drug-influenced gingivitis a) oral contraceptive-associated gingivitis b) other 4. Gingival diseases modified by malnutrition a. ascorbic acid-deficiency gingivitis b. other B. Non-plaque-induced gingival lesions 1. Gingival diseases of specific bacterial origin a. Neisseria gonorrhea-associated lesions b. Treponema pallidum-associated lesions c. streptococcal species-associated lesions d. other 2. Gingival diseases of viral origin a. herpes virus infections 1) primary herpetic gingivostomatitis 2) recurrent oral herpes 3) varicella-zoster infections b. other 3. Gingival diseases of fungal origin a. Candida-species infections 1) generalized gingival candidosis b. linear gingival erythema c. histoplasmosis


d. other 4. Gingival lesions of genetic origin a. hereditary gingival fibromatosis b. other 5. Gingival manifestations of systemic conditions a. mucocutaneous disorders 1) lichen planus 2) pemphigoid 3) pemphigus vulgaris 4) erythema multiforme 5) lupus erythematosus 6) drug-induced 7) other b. allergic reactions 1) dental restorative materials a) mercury b) nickel c) acrylic d) other 2) reactions attributable to a) toothpastes/dentifrices b) mouth rinses/mouth washes c) chewing gum additives d) foods and additives 3) other 6. Traumatic lesions (factitious, iatrogenic, accidental) a. chemical injury b. physical injury c. thermal injury 7. Foreign body reactions 8. Not otherwise specified (NOS) II. Chronic Periodontitis†

A. Localized B. Generalized III. Aggressive Periodontitis† A. Localized B. Generalized IV. Periodontitis as a Manifestation of Systemic Diseases A. Associated with hematological disorders 1. Acquired neutropenia 2. Leukemias 3. Other B. Associated with genetic disorders 1. Familial and cyclic neutropenia 2. Down syndrome 3. Leukocyte adhesion deficiency syndromes 4. Papillon-Lefèvre syndrome 5. Chediak-Higashi syndrome 6. Histiocytosis syndromes 7. Glycogen storage disease 8. Infantile genetic agranulocytosis


9. Cohen syndrome 10. Ehlers-Danlos syndrome (Types IV and VIII) 11. Hypophosphatasia 12. Other C. Not otherwise specified (NOS) V. Necrotizing Periodontal Diseases A. Necrotizing ulcerative gingivitis (NUG) B. Necrotizing ulcerative periodontitis (NUP) VI. Abscesses of the Periodontium A. Gingival abscess B. Periodontal abscess C. Pericoronal abscess VII. Periodontitis Associated With Endodontic Lesions A. Combined periodontic-endodontic lesions VIII. Developmental or Acquired Deformities and Conditions A. Localized tooth-related factors that modify or predispose to plaque-induced gingival diseases/periodontitis 1. Tooth anatomic factors 2. Dental restorations/appliances 3. Root fractures 4. Cervical root resorption and cemental tears B. Mucogingival deformities and conditions around teeth 1. Gingival/soft tissue recession a. facial or lingual surfaces b. interproximal (papillary) 2. Lack of keratinized gingiva 3. Decreased vestibular depth 4. Aberrant frenum/muscle position 5. Gingival excess a. pseudopocket b. inconsistent gingival margin c. excessive gingival display d. gingival enlargement (See I.A.3. and I.B.4.) 6. Abnormal color C. Mucogingival deformities and conditions on edentulous ridges 1. Vertical and/or horizontal ridge deficiency 2. Lack of gingiva/keratinized tissue 3. Gingival/soft tissue enlargement 4. Aberrant frenum/muscle position 5. Decreased vestibular depth 6. Abnormal color D. Occlusal trauma 1. Primary occlusal trauma 2. Secondary occlusal trauma * Can occur on a periodontium with no attachment loss or on a periodontium with attachment loss that is not progressing. †Can be further classified on the basis of extent and severity. As a general guide, extent can be characterized as Localized = <30% of sites involved and Generalized = >30% of sites involved. Severity


can be characterized on the basis of the amount of clinical attachment loss (CAL) as follows: Slight = 1 or 2 mm CAL, Moderate = 3 or 4 mm CAL, and Severe = >5 mm CAL. The Annals of Periodontology, volume 4, contains the complete proceedings of the 1999 International Workshop for a Classification of Periodontal Diseases and Conditions, including the literature reviews and consensus reports on each of the classifications. The Annals of Periodontology, volume 4, may be accessed online at www.joponline.org/toc/annals/4/1


Section 2 Statements of the American Academy of Periodontology Regarding Dental Health Plans as Related to Periodontics The American Academy of Periodontology recognizes that dental benefit plans assist patients in obtaining dental care, thereby fostering better dental health in the United States. The Academy also recognizes the importance of preventive oral health practices in affording all individuals an opportunity to achieve optimal oral and systemic health. Therefore, it is the position of the Academy that dental benefit plans should include provisions for preventive periodontal (dental) care, including oral hygiene instruction and periodontal maintenance procedures at regular intervals as determined by the therapist. Philosophy The long-standing AAP philosophy on third party reporting is: You are treating the patient, not the insurance policy. The treatment plan should be developed according to professional standards rather than the provisions of the benefits contract. Total Case Plan Treatment rationale should be dictated by thorough diagnostic procedures and evaluation of many factors. See the Academy’s Statement on Comprehensive Periodontal Therapy (http://www.perio.org/resources-products/pdf/periodontal-therapy_statement.pdf) and Parameters of Care (http://www.perio.org/resources-products/pdf/parameters.pdf). The resulting treatment plan should be based upon the correlation of information gained through these diagnostic and evaluation procedures and should include services to be provided by the general dentist and dental specialists. It should be presented to the patient on a total treatment basis at the time of consultation. Preventive Care Almost three-quarters of all adults have some signs of periodontal disease. A significant number have lost some or all of their teeth. Many of those with teeth have severe and extensive periodontal problems. Since the disease process often starts early in life and there is growing evidence of associations between periodontal diseases and systemic health, the importance of preventive dental care and early definitive periodontal therapy cannot be overemphasized for the maintenance of good health. Dental care plans that make provisions for preventive dental care and periodontal treatment best serve the interests of the general public. The Academy, therefore, strongly supports the inclusion of reasonable allowances for preventive and comprehensive dental care and the definitive treatment of periodontal diseases in all dental benefit plans. Relationship of Periodontal Diseases and Systemic Health There is an emerging body of evidence linking periodontal diseases with several systemic conditions. Among them are coronary heart disease, stroke, diabetes mellitus, premature delivery of low birth-weight babies, and respiratory infections. There also is some evidence suggesting that periodontal treatment may improve systemic health and even lower the cost of medical care. Complications of these and other systemic diseases and their treatment also may affect periodontal health. Recognition of these interactions is important for the total health of the patient, and should be addressed by both dental and medical benefit plans. Current Therapy Current periodontal therapy consists of a number of surgical and non-surgical procedures designed to halt the progression of attachment loss and, in some instances, restore structures destroyed by disease and replace missing teeth. These procedures have been developed through a combination of increased basic knowledge, clinical studies, and modern materials and technology.


Surgical procedures consist of multiple resective, regenerative, reconstructive, and implant techniques. These address specific periodontal problems and are frequently used in combination in order to achieve a level and predictability of results not previously possible. The Academy is prepared to serve as a resource to those parties who wish to become more knowledgeable about the scope of current periodontal procedures. Extent and Location of Treatment The extent of periodontal treatment carried out in a single day should be determined by the periodontist after evaluation of the unique needs of the patient. The health of the patient, not the terms of the dental benefit plan, must be primary in all treatment decisions, including the need for analgesia, conscious sedation, or general anesthesia. Similarly, the site for periodontal treatment should be determined by the periodontist after evaluation of the patient. Hospitalization benefits should be available for those patients whose condition, in the professional judgment of the dentist, requires the resources of a hospital for optimal treatment. Pre-determination of Benefits Both patient and dentist should understand the benefits provided by a dental benefit plan. Predetermination of benefits enables both the patient and the dentist to be informed of the limitations of eligibility, the application of deductibles, co-payments, yearly maximums and coinsurance factors, dollar limits on coverage, and the imposition of an alternate benefit clause – before the initiation of treatment. Predetermination is not an absolute commitment by a third party carrier that payment will be made. Employment termination, contract expiration, maximum allowances, other dental care provided during the same benefit period, etc., may cause the benefit paid to differ from the predetermined amount. Also, some benefit carrier contracts require a predetermination before treatment can be completed. In some instances a previously approved pre-determination of benefits may not be honored by the carrier:

• At the time the pre-determination was processed by the carrier, the patient was eligible for benefits when treatment was provided and the claim was received by the carrier also, if the patient was no longer employed by his/her employer and thus was not eligible for the benefits.

• At the time the pre-determination was processed by the carrier, the patient had benefit dollars available; however, when treatment was provided and the claim processed the patient had reached his/her annual maximum benefit and benefit dollars were no longer available.

When the patient is covered by more than one dental benefit plan, the secondary carrier’s predetermination may state that benefits are subject to revision because of coordination of benefits since the amount of the primary carrier’s benefit is not known. Coordination of benefits may take several forms. Most common is one where the secondary carrier will pay the difference between what it would have paid had it been primary (subject, of course, to its own annual maximum) and what the actual primary carrier benefited. For example, for a procedure having a $1900 fee, if the primary carrier paid $950 (50% of the fee) and the secondary carrier would have provided a $1520 benefit (80%), then it would pay $570. If the primary policy had 80% coinsurance ($1520) and benefited the full amount, the secondary carrier benefit would have been zero regardless of what the estimated benefit was. Some plans have a “non-duplication of benefits” provision which means that what the primary carrier paid will not be duplicated by the secondary carrier. Thus, for the same $1900 fee if the primary carrier paid $760, that amount counts toward the annual maximum as if the secondary carrier had paid it and only $240 remains to reach its annual maximum of $1000, so that would be the total benefit from the secondary carrier.


There are other, less common, variations and all are subject to state laws which may impose other conditions. It is important to note that it is the plan purchaser (the employer), not the dental benefits carrier, who determines the provisions of the contract. Most patients, particularly those who work for larger employers, are covered under ASO (administrative services only) contracts, so it is the employer’s money not the carrier’s that is at stake. Most Inclusive Service Often a number of procedures are grouped together with benefits limited to those available for “the most inclusive procedure.” The most common example is osseous surgery. This procedure is defined in this publication and historically has included elevation of a soft tissue flap, reshaping the underlying bone, and flap closure. Soft tissue grafts, bone replacement grafts, guided tissue regeneration, biologic modifiers, and other procedures are distinctly separate from osseous surgery and should be considered for benefits even though they may be performed at the same visit in the same area of the mouth. Procedures such as bone replacement grafts, guided tissue regeneration, and biologic modifiers cannot be performed without an access surgery (osseous surgery or gingival flap procedure) so providing benefits only for the “most inclusive service” actually denies benefits for covered procedures. Periodontal Consultants The American Academy of Periodontology encourages third party carriers to utilize periodontal consultants in the claims review process. A periodontal consultant is a dentist who is educationally qualified and knowledgeable about the current range of periodontal services, techniques, and materials. He or she also should be familiar with the etiologies and pathogenesis of the various periodontal diseases and the diagnostic and therapeutic modalities used in managing those diseases. The periodontal consultant is employed by the administrator or provider of dental care programs to give professional advice in the adjudication of periodontal claims. He or she evaluates submitted claims either for the predetermination of benefits or payment when the services have been rendered. Peer Review Programs State dental associations conduct peer review programs to settle disputes between patients and dentists, or third party payers and dentists. Disputes that may be addressed through peer review involve appropriateness of care, quality of care, or whether a fee in question is the dentist’s usual fee for a procedure, based on the difficulty or complexity of the dental procedure. Appropriateness of care is defined as “the professional acceptability of planned or completed treatments, to include the necessity and consistency with diagnosis.” Thus, it would include treatment plans and predetermination of benefits. Quality of treatment “concerns an evaluation of the treatment provided using the standards of care which generally prevail within the profession by those who routinely perform the treatment in question.” The ADA Peer Review Manual further states that “with respect to review of cases involving treatment in specialty areas, the underlying principle remains that there is one standard of care regardless of who provides the care.” The procedure for initiating peer review is to contact the component (local) dental society and request peer review. The component society conducts the peer review and conveys its decision to the dentist and other parties involved in the peer review. Under some circumstances, decisions of the peer review committee at the component level can be appealed to the state dental association by either the dentist or the other involved party. Periodontal Records In order to determine appropriate benefits, carriers may require information beyond that supplied with


the original claim form. The American Academy of Periodontology feels that dentists should comply with reasonable requests from third party payers for information regarding services provided to patients covered under a plan. View the Academy’s Policy Statement for Third Party Requests for Periodontal Records (http://www.perio.org/members/tpi/policy/policy10.html). However, each dentist must make an individual determination regarding how to respond to such requests. Dental Claim Forms The American Academy of Periodontology endorses the Dental Claim Form designed by the American Dental Association. Use by dentists and dental benefit plans of that form and the current ADA Code on Dental Procedures and Nomenclature will enhance efficiency in the reporting and processing of dental claims, particularly with the increased use of electronic claim processing. Reporting Services Few dental prepayment plans provide comprehensive treatment benefits solely on the basis of the periodontal diagnosis, i.e., without specifying services on a claim form or electronic submission. Modern periodontal therapy often requires a number of complex procedures and additional benefits should be provided for them. Utilization Review Statistically-based utilization review examines the distribution of treatment procedures based on claims information. In order to be reasonably accurate, the application of such claims analysis of specific dentists should include data on type of practice, socioeconomic characteristics, and geographic location of the practice and the dentist’s experience. Statistically based utilization review should not be used to determine acceptable norms or clinical standards of dental practice. Freedom of Choice The Academy believes that a patient has the right to choose any licensed dentist to deliver his/her care without any type of coercion. Dental benefit plans that restrict patients’ choice of dentist should not be the only plans offered to subscribers. Patients should have the option to choose a plan that affords an unrestricted choice of dentist with comparable benefits and equal premium dollars. All dentists should have the right to participate in any dental prepayment plan, provided that the dentist is professionally qualified and willing to accept the limitations imposed by the plan. The dentist also should have the right, while in compliance with applicable laws, to selectively accept patients. Fee-for-Service Plans In order to ensure the patient’s free choice of dentist, the Academy urges that employers offer a fee-for-service option when an alternative benefit plan is provided. That option should provide equal or comparable benefits to those obtained under the alternative plan and should have equal premium dollars allocated to it. Under the fee-for-service option, the fee for periodontal services is an agreement between the patient and the dentist. The patient is responsible to the dentist for the total payment for services rendered. In addition, each dentist should have the right to determine whether to accept payment directly from a third party payer.


Dental Benefit Plans Rather than traditional “insurance” in which the carrier is at risk if costs exceed premiums, most dental benefit plans are Administrative Services Only (ASO) contracts. The American Dental Association defines them as “an arrangement under which a third party, for a fee, processes claims and handles paperwork for a self-funded group. This frequently includes all insurance company services (actuarial services, underwriting, benefit description, etc.) except assumption of risk.” Claims are processed for a set fee and benefits are paid out with the plan purchaser’s funds. Administrative fees are negotiated by the purchaser and carrier and are usually on a per claim or per line item basis. The plan purchaser (usually an employer of over 100 people) determines the procedures to be covered and may even set the carrier’s reimbursement guidelines. In some cases, reimbursement checks are drawn on the purchaser’s account, but most often the carrier acts as a “paying agent” for the employer. Carriers are audited regularly to determine if claims have been paid appropriately and must reimburse the purchaser for claims paid in error. A. Traditional Dental Benefit Plans Traditional dental benefit plans are generally referred to as “indemnity” or “fee-for-service” plans. These plans allow patients to seek care from the general dentist or specialist of their choice. There is no contractual relationship between the dentist and third party, so dentists assume no financial risk. Some of these plans are “insured”. That is, the third party bears the financial risk for the cost of providing defined categories or services to a defined group of beneficiaries. If the cost of providing those services is greater than the premium collected, the third party suffers the loss. On the other hand, if the cost is less than the premium, the third party makes a profit. Traditional plans pay the dentist for services provided, based on the fee that the third party has determined is “usual, customary, and reasonable” (UCR), or according to a table of allowances or fee schedule. The concept for these definitions was adapted from the ADA Current Dental Terminology, 8th Edition (CDT-2011-2012). These payment mechanisms are described below: Usual, Customary, and Reasonable (UCR) • Usual: The fee that an individual dentist most frequently charges for a specific dental procedure. • Customary: The maximum benefit payable under a given plan for that specific procedure. This fee level is determined by the administrator of a dental benefit plan from actual submitted fees for a specific dental procedure. • Reasonable: The fee charged by a dentist for a specific dental procedure that has been modified by the nature and severity of the condition being treated and by any medical or dental complications, or unusual circumstances. Therefore, a “reasonable” fee may differ from the dentist’s “usual” fee or the benefit administrator’s “customary” fee. Most carriers do not differentiate between general dentists and specialists in determining UCR. When a third party carrier benefits a procedure based on UCR, the benefits available are usually only a percentage of the dental office’s charges for the service. The patient is responsible for paying the difference. The level of reimbursement may also depend on the type of treatment (e.g., preventive services, basic care, major, restorative, etc.), with benefits usually ranging from 50 to 100 percent. Most dental benefit plans provide that periodontal services are benefited at 80 percent. Sometimes, however, periodontal surgery is classified as a major procedure and is benefited at 50 percent. Example: Your fee for a periodontal procedure performed on a patient is $100. The insurance company states that the “usual, customary, and reasonable fee” for that procedure is $90. The procedure is covered at 80 percent, so the patient would receive 80 percent of $90, or $72. The patient is responsible


for the balance of $28 unless your contract with the third party carrier mandates that you not bill the patient for the difference. Table of Allowances or Fee Schedule These plans list covered services with an “allowed” dollar amount for each service. The schedule usually does not equal the dentist’s full charge for the services. The patient pays the difference. Example: The schedule might list $70 for a covered service, but your office charges $110. The plan would pay $70 and the patient would be responsible for the $40 difference. Some plans may pay a percentage of the allowed charge, again with the patient being responsible for the balance. This type of plan is becoming more prevalent because it is less expensive to administer. A procedure is either covered at a certain amount, or it is not covered at all. Some insurance contracts will say that any procedure performed for a covered patient that is not indicated on the table will be benefited based upon a comparable, or perhaps lesser, procedure on the table. The patient is still responsible for the balance. B. Health Savings Accounts Health Savings Accounts (HSAs) are funded by patients and/or employers to save for future medical expenses. Contributions up to prescribed limits are tax deductible even if the patient does not itemize deductions. These accounts must be combined with an HSA-qualified “high deductible health plan” (HDHP) which can be obtained from virtually any company that sells health insurance coverage. Employees own and are responsible for the funds in their health savings account. Therefore, decisions on how to utilize the funds are made by the employee without interference from an insurance company. The funds in an account may be used to pay for current medical or dental expenses, including expenses not covered by insurance, or saved for future use such as after retirement and long-term care expenses, including insurance. More information is available at http://www.treas.gov/offices/public-affairs/hsa/ C. Direct Reimbursement These plans require the patient to pay the providing dentist and submit a receipt to the employer for partial or full reimbursement. In some cases, a third party administrator (TPA) may be involved to handle the bookkeeping. Direct reimbursement is unique in that it bypasses clinical review. Usually, all covered services are reimbursed equally up to a yearly predetermined dollar amount. Example: A direct reimbursement plan may cover 80 percent of all preventive, emergency, and periodontal care up to $1,200 each year. The patient has an implant placed for a total cost of $1,000. The patient is reimbursed 80 cents for each dollar or $800. The patient has $400 remaining until the plan has paid $1,200 that year on dental services. Dental Benefit Resources DBIS – Dental Benefit Information Service: ADA telephone 800/621-8099. This service is offered by the American Dental Association (ADA) concerning any information on direct reimbursement plans. D. Managed Care Dental Benefit Plans Alternative dental benefit plans contract for patient care with a limited number of dentists, otherwise known as a closed panel of providers. Financial incentives encourage patients to seek care only from those dentists. Some common forms of alternative benefit plans are described below.


1. Dental Health Maintenance Organizations (DHMO) Capitation Plans/Prepaid Plans In a prepaid plan, the contracting dentist is paid the same amount every month for each enrolled patient, whether or not the patient comes to the office for treatment. The dentist provides all the covered services that the beneficiaries, usually called enrollees, require. However, the payment to the dentist may not be sufficient to cover the cost of treatment. The dentist would be responsible for the balance of the cost of treatment not covered. In this way, financial risk for high utilization of services is transferred to the dentist, which may result in undertreatment. Dentists in a prepaid plan practice in their own offices and also accept patients not enrolled in the plan. A Dental Health Maintenance Organization (DHMO) is an example of a prepaid plan. Specialists participating in a prepaid plan generally are paid according to a predetermined fee schedule which usually reflects a discount from usual fees. Patient co-payments for more expensive procedures such as periodontal surgery and crowns usually are a part of prepaid plans. 2. Preferred Provider Organization (PPO) In this type of plan, dentists enter into an agreement with an insurer, employer, or third party administrator to discount fees for dental services to employees of designated companies. In return, the employer publicizes the agreement to the employees, giving them a financial incentive to visit the PPO dentists. In many PPOs, the patient can receive benefits for treatment received from a non- participating dentist. However, since the dentist has no contractual relationship with the carrier, the patient is responsible for the full fee so may pay more out-of-pocket than if a participating dentist provided care. A typical plan design for a PPO plan would provide: 100% coverage for preventive and diagnostic services $50 annual deductible applies to all services except preventive and diagnostic services 80% coverage for basic restorative services 50% coverage for major restorative services 50% coverage for orthodontics subject to separate lifetime maximum of $1000 $1,000 annual maximum for all services except orthodontics 3. Service Corporation Service corporations or “service benefit plans” are established under not-for-profit state statutes for the purpose of providing health care coverage. Examples of service corporations are Delta Dental Plans and Blue Cross/Blue Shield plans. Participating dentists contract with the service corporations. Benefits are greater when the patient is treated by a participating dentist than when treated by a non-participating dentist. Most managed care plans have a contract provision limiting patient financial responsibility for non-covered procedures to what the plan would have benefited had the procedure been covered. The dentist cannot bill the patient for the balance. The carrier probably would treat any agreement between the dentist and the patient making the patient responsible for those non-covered charges as a breach of contract and bring legal action to enforce the contract. A number of states have passed laws forbidding this type of action by carriers, but they do not apply to Employment Retirement Income Security Act (ERISA) plans which are governed by federal law under the


Department of Labor. Most union-negotiated plans come under ERISA. Some of those state laws also exempt ASO (Administrative Services Only) contracts. 4. Individual Practice Association (IPA) An IPA is similar to a PPO in that a group of dentists negotiates an agreement with an employer to discount their fees for dental services to the employees. However, an IPA may be organized and operated by the individual participating dentists, with no third party involvement. An IPA is a legal entity that can bargain with employers concerning fees, procedures covered, etc., without violating antitrust laws. In both an IPA and a PPO, the dentists usually practice in their own offices and provide care to patients not covered by the contract. 5. Discount Plans Although providers sign contracts to be part of the “network” and a fee schedule is implemented, the patient is responsible for the entire cost of service. Discount plans usually are marketed to individuals or to members who opt for coverage within larger groups that offer the plans as a membership benefit. The enrollment fee is retained by the marketing group with no portion paid to the dentist. There is no third party involvement in either treatment or payment. 6. Point of Service Plans Point of service options are arrangements in which patients with a managed care dental plan have the option of seeking treatment from an ‘out-of-network” provider. The reimbursement to the patient is usually based on a table of allowances with contracted dentists agreeing to accept that amount as payment in full. Treatment by an out-of-network dentist may result in reduced benefits and the patient will be responsible for the difference between the benefit provided and the dentist’s fee. 7. Medicare Medicare will only pay for dental services that are an integral part either of a covered procedure (e.g., reconstruction of the jaw following accidental injury) or for extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw. Coverage is not determined by the value or the necessity of the dental care but by the type of service provided and the anatomical structure on which the procedure is performed.“


Section 3 Description of Selected Procedural Codes This section discusses codes commonly used by periodontists. Additional information about the codes has been supplied by the Academy. The fourteenth revision of the ADA’s Code on Dental Procedures and Nomenclature became effective on January 1, 2011 and those codes must be used for all claims submissions after that date. The entire Code on Dental Procedures and Terminology is published in CDT-2011: Current Dental Terminology, Copyright 2010, American Dental Association. If you would like to purchase CDT-2011 you may contact ADA Salable Materials at 800/947-4746; or online at www.adacatalog.org. Diagnostic Clinical Oral Evaluations The codes in this section recognize the cognitive skills necessary for patient evaluation. The collection and recording of some data and components of the dental examination may be delegated; however, the evaluation, which includes diagnosis and treatment planning, is the responsibility of the dentist. As with all ADA procedure codes, there is no distinction made between the evaluations provided by general practitioners and specialists. Report additional diagnostic and/or definitive procedures separately. D0120 periodic oral evaluation – established patient An evaluation performed on a patient of record to determine any changes in the patient’s dental and medical health status since a previous comprehensive or periodic evaluation. This includes an oral cancer evaluation and periodontal screening where indicated, and may require interpretation of information acquired through additional diagnostic procedures. Report additional diagnostic procedures separately. D0140 limited oral evaluation – problem focused An evaluation limited to a specific oral health problem or complaint. This may require interpretation of information acquired through additional diagnostic procedures. Report additional diagnostic procedures separately. Definitive procedures may be required on the same date as the evaluation. Typically, patients receiving this type of evaluation present with a specific problem and/or dental emergencies, trauma, acute infections, etc. D0150 comprehensive oral evaluation – new or established patient Used by a general dentist and/or specialist when evaluating a patient comprehensively. This applies to new patients; established patients who have had a significant change in health conditions or other unusual circumstances, by report, or established patients who have been absent from active treatment for three or more years. It is a thorough evaluation and recording of the extraoral and intraoral hard and soft tissues. It may require interpretation of information acquired through additional diagnostic procedures. Additional diagnostic procedures should be reported separately. This includes an evaluation for oral cancer where indicated, the evaluation and recording of the patient’s dental and medical history and a general health assessment. It may include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, existing prostheses, occlusal relationships, periodontal conditions (including periodontal screening and/or charting), hard and soft tissue anomalies, etc.


D0160 detailed and extensive oral evaluation – problem focused, by report A detailed and extensive problem focused evaluation entails extensive diagnostic and cognitive modalities based on the findings of a comprehensive oral evaluation. Integration of more extensive diagnostic modalities to develop a treatment plan for a specific problem is required. The condition requiring this type of evaluation should be described and documented. Examples of conditions requiring this type of evaluation may include dentofacial anomalies, complicated perio-prosthetic conditions, complex temporomandibular dysfunction, facial pain of unknown origin, conditions requiring multi-disciplinary consultation, etc. D0170 re-evaluation – limited, problem focused (established patient; not post-

operative visit) Assessing the status of a previously existing condition. For example – a traumatic injury where no treatment was rendered but patient needs follow-up monitoring; - evaluation for undiagnosed continuing pain; - soft tissue lesion requiring follow-up evaluation. D0180 comprehensive periodontal evaluation – new or established patient This procedure is indicated for patients showing signs and symptoms of periodontal disease and for patients with risk factors such as smoking or diabetes. It includes evaluation of periodontal conditions, probing and charting, evaluation and recording of the patient’s dental and medical history and general health assessment. It may include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, occlusal relationships and oral cancer evaluation. D9310 consultation – diagnostic service provided by dentist or physician other then

requesting dentist or physician A patient encounter with a practitioner whose opinion or advice regarding evaluation and/or management of a specific problem; may be requested by another practitioner or appropriate source. The consultation includes an oral evaluation. The consulted practitioner may initiate diagnostic and/or therapeutic services. D9450 case presentation, detailed and extensive treatment planning Established patient. Not performed on same day as evaluation. Radiographs/Diagnostic Imaging (Including Interpretation) Should be taken only for clinical reasons as determined by the patient’s dentist. Should be of diagnostic quality and properly identified and dated. Is a part of the patient’s clinical record and the original images should be retained by the dentist. Originals should not be used to fulfill requests made by patients or third-parties for copies of records. Click here for the AAP’s policy statement on Radiographs in Periodontics (http://www.perio.org/members/tpi/policy/policy13.html); Postoperative Radiographs (http://www.perio.org/members/tpi/policy/policy7.html); Requests for Preoperative Radiographs for Soft Tissue Procedures (http://www.perio.org/members/tpi/policy/policy8.html). Additional links for ADA HHS Guidelines are http://www.ada.org/prof/resources/topics/radiography.asp#radiographs http://www.ada.org/prof/resources/topics/topics_radiography_chart.pdf D0210 intraoral - complete series (including bitewings) A radiographic survey of the whole mouth, usually consisting of 14-22 periapical and posterior bitewing images intended to display the crowns and roots of all teeth, periapical areas and alveolar bone. D0220 intraoral - periapical first film D0230 intraoral – periapical each additional film


D0270 bitewing – single film D0272 bitewings – two films D0273 bitewings – three films D0274 bitewings – four films D0277 vertical bitewings –7 to 8 films This does not constitute a full-mouth intraoral radiographic series. D0322 tomographic survey D0330 panoramic film See the AAP’s (Policy Statement Radiographs in Periodontics; http://www.perio.org/members/tpi/policy/policy13.html) D0350 oral/facial photographic images This includes photographic images, including those obtained by intraoral and extraoral cameras, excluding radiographic images. These photographic images should be a part of the patient’s clinical record. D0360 cone beam ct. – craniofacial data capture

Includes axial, coronal and sagittal data D0362 cone beam - two dimensional image reconstruction using existing data, includes

multiple images D0363 cone beam - three dimensional image reconstruction using existing data,

includes multiple images Tests and Examinations D0415 collection of microorganisms for culture and sensitivity D0421 genetic test for susceptibility to oral diseases Sample collection for the purpose of certified laboratory analysis to detect specific genetic variations associated with increased susceptibility for oral diseases such as severe periodontal disease. D0431 adjunctive pre-diagnostic that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures D0460 pulp vitality tests Includes multiple teeth and contra lateral comparison(s), as indicated D0470 diagnostic casts Also known as diagnostic models or study models.


Preventive Procedures D1110 prophylaxis Removal of plaque, calculus, and stains from the tooth structures in the permanent and transitional dentition. It is intended to control local irritational factors. This code descriptor no longer limits its use to patients in “good periodontal health” so it may be used when gingivitis is present. It is not synonymous with a periodontal maintenance procedure (D4910) and should not be alternated with that procedure in order to maximize dental benefits. Some carriers will provide an additional benefit for a “difficult prophylaxis,” but will require a narrative indicating the patient’s presenting features that require additional time to complete the procedure. D1310 nutritional counseling for control of dental disease Counseling on food selection and dietary habits as a part of treatment and control of periodontal disease and caries. D1320 tobacco counseling for the control and prevention of oral disease D1330 oral hygiene instructions This may include instructions for home care. Examples include tooth brushing technique, flossing, use of special oral hygiene aids. This is an integral part of initial periodontal therapy. Crowns D2799 provisional crown Crown utilized as an interim restoration of at least six months duration during restorative treatment to allow adequate time for healing or completion of other procedures. This includes, but is not limited to changing vertical dimension, completing periodontal therapy or cracked-tooth syndrome. This is not to be used as a temporary crown for a routine prosthetic restoration. Other Restorative Services D2920 recement crown Endodontics D3450 root amputation – per root Root resection of a multi-rooted tooth while leaving the crown. If the crown is sectioned, see D3920. This is a unique procedure and should be reported separately even when performed in conjunction with a periodontal procedure such as gingival flap or osseous surgery. D3920 hemisection (including any root removal), not including root canal therapy Includes separation of a multi-rooted tooth into separate sections containing the root and the overlying portion of the crown. It may also include the removal of one or more of those sections. This is a unique procedure and should be reported separately even when performed in conjunction with a periodontal procedure such as gingival flap or osseous surgery.


Periodontal Procedures All periodontal procedures include routine postoperative care and local anesthesia. When a periodontal procedure other than a soft tissue graft crosses the midline, each quadrant should be reported separately. Tooth numbers should be reported for procedures involving less than four teeth, osseous grafts, biologic materials to aid in regeneration of periodontal tissues, bone replacement grafts, soft tissue grafts, crown lengthening procedures, and localized delivery of antimicrobial agents. Periodontal Surgical Procedures Flap elevation and closure also is included in the codes for anatomical crown exposure, gingival flap, apically positioned flap, osseous surgery, surgical revision, and distal or proximal wedge procedures. The term “site” as used in the following procedures is defined as: A term used to describe a single area, position, or locus. The word “site” is frequently used to indicate an area of soft tissue recession on a single tooth or an osseous defect adjacent to a single tooth; also used to indicate soft tissue defects and/or osseous defects in edentulous tooth positions.

• If two contiguous teeth have areas of soft tissue recession, each area of recession is a single site

• If two contiguous teeth have adjacent but separate osseous defects, each defect is a single site.

• If two contiguous teeth have a communicating interproximal osseous defect, it should be considered a single site.

• All non-communicating osseous defects are single sites.

• All edentulous non-contiguous tooth positions are single sites.

Depending on the dimensions of the defect, up to two contiguous edentulous tooth positions may be considered a single site. Several of the following surgical procedure codes refer to “four or more contiguous teeth or tooth bounded spaces, per quadrant” or “less than four contiguous teeth or tooth bounded spaces, per quadrant.” Bounded tooth spaces are those edentulous areas between teeth. They may encompass the areas previously occupied by one or more teeth. For example, the patient is missing teeth #s 4 and 5. The area between #s 3 and 6 is considered a bounded tooth space. That region would be considered less than four contiguous teeth or bounded tooth spaces because only two teeth and one bounded tooth space would be included in the surgical procedure. If #2 also required treatment, the region then would be considered four or more teeth or bounded tooth spaces and coded accordingly. Academy Parameters of Care (http://www.perio.org/resources-products/pdf/parameters.pdf), Position Papers (http://www.perio.org/resources-products/posppr3-3.html) and Policy Statements (http://www.perio.org/members/tpi/policy/policy17.html) can also be found at www.perio.org. As a reminder, these policy statements are only available to AAP Members. D4210 gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant Involves the excision of the soft tissue wall of the periodontal pocket by either an external or an internal bevel. It is performed to eliminate suprabony pockets after adequate initial preparation, to allow access for restorative dentistry in the presence of suprabony pockets, or to restore normal architecture when gingival enlargements or asymmetrical or unaesthetic topography is evident with normal bony configuration.


D4211 gingivectomy or gingivoplasty – one to three contiguous teeth or tooth bounded spaces per quadrant Involves the excision of the soft tissue wall of the periodontal pocket by either an external or an internal bevel. It is performed to eliminate suprabony pockets after adequate initial preparation, to allow access for restorative dentistry in the presence of suprabony pockets, or to restore normal architecture when gingival enlargements or asymmetrical or unaesthetic topography is evident with normal bony configuration.

D4230 anatomical crown exposure – four or more contiguous teeth per quadrant This procedure is utilized in an otherwise periodontally healthy area to remove enlarged gingival tissue and supporting bone (ostectomy) to provide an anatomically correct gingival relationship. Enlarged gingival tissues may result from a number of causes, including drugs such as Dilantin, mouth breathing, irritation from orthodontic appliances, poor oral hygiene, and heredity. These reconstructive procedures are performed on abnormal tissues in order to restore normal function. While doing so, there might also be an improvement in appearance. Particularly in young patients, the supporting alveolar bone may be at the cemento-enamal junction, possibly leading to regrowth of the enlarged gingival tissue. In those cases, it is necessary to also remove some supporting bone (ostectomy) to allow biologic width for healthy gingiva. If only the enlarged gingival tissue is removed, D4210 or D4211 is the proper code to use.

D4231 anatomical crown exposure – one to three teeth per quadrant See D4230 descriptor. D4240 gingival flap procedure, including root planing – four or more contiguous teeth or tooth bounded spaces per quadrant A soft tissue flap is reflected or resected to allow debridement of the root surface and the removal of granulation tissue. Osseous recontouring is not accomplished in conjunction with this procedure. May include open flap curettage, reverse bevel flap surgery, modified Kirkland flap procedure, and modified Widman surgery. This procedure is performed in the presence of moderate to deep probing depths, loss of attachment, need to maintain esthetics, need for increased access to the root surface and alveolar bone, or to determine the presence of a cracked tooth, fractured root, or external root resorption. Other procedures may be required concurrent to D4240 and should be reported separately using their own unique codes. These procedures provide access for placement of bone replacement grafts (D4263 and D4264), guided tissue regeneration barriers (D4266 or D4267), and biologic materials to aid in soft and osseous tissue regeneration (D4265) when osseous recontouring is not needed. It is reported in addition to codes for those procedures. D4241 gingival flap procedure, including root planing – one to three contiguous teeth or tooth bounded spaces per quadrant See D4240 descriptor. D4245 apically positioned flap Procedure is used to preserve keratinized gingiva in conjunction with osseous resection and second stage implant procedure. Procedure may also be used to preserve keratinized/attached gingiva during surgical exposure of labially impacted teeth, and may be used during treatment of peri-implantitis. D4249 clinical crown lengthening – hard tissue This procedure is employed to allow restorative procedure or crown with little or no tooth structure exposed to the oral cavity. Crown lengthening requires reflection of a flap and is performed in a healthy periodontal environment, as opposed to osseous surgery, which is performed in the presence of periodontal disease. Where there are adjacent teeth, the flap design may involve a larger surgical area.


It should not be used to report removal of excess gingival tissues for correction of a “gummy” smile. Use D4210/4211 (if no bone is removed) or D4230/4231 (if bone is removed) for those procedures. Crown lengthening is a “per tooth” procedure even though treatment of a single tooth usually will involve a minimum of three teeth so report the number of the teeth requiring treatment. Clinical crown lengthening is usually performed due to subgingival caries, a fractured cusp, etc. When disease is present and it is necessary to remove bone and perform osseous recontouring, use code D4260/61, osseous surgery. Usually is not benefited if performed with a crown already in place. Sufficient healing time (usually at least six weeks) must elapse before crown placement. This code also may be used when caries extends beyond the margin of alveolar bone and an amalgam or composite restoration is to be used. The general dentist or the periodontist usually places the restoration on the same day as the surgery, so a brief narrative explaining the situation should accompany the claim. View the Academy’s policy statement on Surgical Crown Lengthening (http://www.perio.org/members/tpi/policy/policy17.html). D4260 osseous surgery (including flap entry and closure) four or more contiguous teeth or tooth bounded spaces per quadrant This procedure modifies the bony support of the teeth by reshaping the alveolar process to achieve a more physiologic form. This may include the removal of supporting bone (ostectomy) and/or non-supporting bone (osteoplasty). Other procedures [such as placement of bone replacement grafts (D4263/D4264), biologic materials to aid in hard tissue regeneration (D4265), or barrier membranes for guided tissue regeneration (D4266/D4267)] may be required concurrent to D4260 and should be reported using their own unique codes. Osseous surgery involves removal of bone in the presence of periodontal disease while crown lengthening (D4249) is performed in a healthy periodontal environment. However, if crown lengthening is performed in the same surgical area as osseous surgery, the combined procedure should be reported as osseous surgery. D4261 osseous surgery (including flap entry and closure) – one to three contiguous teeth or tooth bounded spaces per quadrant See descriptor D4260 D4263 bone replacement graft – first site in quadrant This procedure involves the use of osseous autografts, osseous allografts, or non-osseous grafts to stimulate periodontal regeneration when the disease process has led to a deformity of the bone. This procedure does not include flap entry and closure, wound debridement, osseous contouring, or the placement of biologic materials to aid in osseous tissue regerneration or barrier membranes. Other separate procedures may be required concurrent to D4263 and should be reported using their own unique codes. Since it is necessary to gain access to the periodontal defect in order to place the membrane, these codes should be reported in addition to those for gingival flap or osseous surgery procedures. D4264 bone replacement graft – each additional site in quadrant See descriptor D4263 D4265 biologic materials to aid in soft and osseous tissue regeneration Biologic materials may be used alone or with other regenerative substrates such as bone and barrier membranes, depending upon their formulation and the presentation of the periodontal defect. This procedure does not include surgical entry and closure, wound debridement, osseous contouring, or the placement of graft materials and/or barrier membranes. Other separate procedures may be required concurrent to D4265 and should be reported using their own unique codes. Even though their costs vary


greatly, a number of materials fall under this code. Since it is necessary to gain access to the periodontal defect in order to place the material, this code should be reported in addition to those for gingival flap or osseous surgery procedures. D4266 guided tissue regeneration - resorbable barrier per site A membrane is placed over the root surfaces or defect area following surgical exposure and debridement. The mucoperiosteal flaps are then adapted over the membrane and sutured. The membrane is placed to exclude epithelium and gingival connective tissue from the healing wound. This procedure may require subsequent surgical procedures to correct the gingival contours. Guided tissue regeneration may also be carried out in conjunction with bone replacement grafts or to correct deformities resulting from inadequate faciolingual bone width in an edentulous area. When guided tissue regeneration is used in association with a tooth, each site on a specific tooth should be reported separately. Other separate procedures may be required concurrent to D4266 and should be reported using their own unique codes. Since it is necessary to gain access to the periodontal defect in order to place the membrane, this code should be reported in addition to those for gingival flap or osseous surgery procedures. D4267 guided tissue regeneration – nonresorbable barrier, per site (includes membrane removal This procedure is used to regenerate lost or injured periodontal tissue by directing differential tissue responses. A membrane is placed over the root surfaces or defect area following surgical exposure and debridement. The mucoperiosteal flaps are then adapted over the membrane and sutured. This procedure does not include flap entry and closure, wound debridement, osseous contouring, bone replacement grafts, or the placement of biologic materials to aid in osseous tissue regeneration. The membrane is placed to exclude epithelium and gingival connective tissue from the healing wound. This procedure requires subsequent surgical procedures to remove the membranes and/or to correct the gingival contours. Guided tissue regeneration may be used in conjunction with bone replacement grafts or to correct deformities resulting from inadequate faciolingual bone width in an edentulous area. When guided tissue regeneration is used in association with a tooth, each site on a specific tooth should be reported separately with this code. When no tooth is present, each site should be reported separately. Other separate procedures may be required concurrent to D4266 and should be reported using their own unique codes. Since it is necessary to gain access to the periodontal defect in order to place the membrane, this code should be reported in addition to those for gingival flap or osseous surgery procedures. D4268 surgical revision procedure, per tooth This procedure is to refine the results of a previously provided surgical procedure. This may require a surgical procedure to modify the irregular contours of hard or soft tissue. A mucoperiosteal flap may be elevated to allow access to reshape alveolar bone. The flaps are replaced or repositioned and sutured. The rationale for this additional procedure should accompany the claim. The following soft tissue graft procedures are utilized to create or augment the attached gingiva, deepen the vestibule, or eliminate frenum involvement. They reestablish health by stopping progressive gingival recession and by creating an anatomy conducive to the maintenance of health by providing gingival coverage of caries-susceptible and sensitive root surfaces. Additional information may be obtained from the AAP’s Parameter of Care for Mucogingival Conditions (http://www.perio.org/resources-products/pdf/861.pdf), Policy Statements on Soft Tissue Grafting, Basic Allowances for Soft Tissue Grafts and Requests for Preoperative Radiographs for Soft Tissue Procedures. Also, the Narrative on Soft Tissue Grafts. All can be found at: http://www.perio.org/members/tpi/policy/policyindex.html#cpr.


Also, a copy of the Academy’s Consensus Paper on Mucogingival Conditions can be found at: http://www.perio.org/members/tpi/policy/policy5.html D4270 – pedicle soft tissue graft procedure A pedicle flap of gingiva can be raised from an edentulous ridge, adjacent teeth, or from the existing gingiva on the tooth and moved laterally or coronally to replace alveolar mucosa as marginal tissue. The procedure can be used to cover an exposed root or to eliminate a gingival defect if the root is not too prominent in the arch. D4271 – free soft tissue graft procedure (including donor site surgery) Gingival or masticatory mucosa is grafted to create or augment the gingiva at another site, with or without root coverage. This graft may also be used to eliminate the pull of frena and muscle attachments, to extend the vestibular fornix, and to correct localized gingival recession. D4273 – subepithelial connective tissue graft procedures, per tooth This procedure is performed to create or augment gingiva, to obtain root coverage to eliminate sensitivity and to prevent root caries, to eliminate frenum pull, to extend the vestibular fornix, to augment collapsed ridges, to provide an adequate gingival interface with a restoration or to cover bone or ridge regeneration sites when adequate gingival tissues are not available for effective closure. There are two surgical sites. The recipient site utilizes split thickness incision, retaining the overlying flap of gingiva and/or mucosa. The connective tissue is dissected from the donor site leaving an epithelialized flap for closure. After the graft is placed on the recipient site, it is covered with the retained overlying flap. D4275 – soft tissue allograft Procedure is performed to create or augment the gingiva, with or without root coverage. This may be used to eliminate the pull of the frena and muscle attachments, to extend the vestibular fornix, and correct localized gingival recession. There is no donor site. D4276 – combined connective tissue and double pedicle graft, per tooth Advanced gingival recession often cannot be corrected with a single procedure. Combined tissue grafting procedures are needed to achieve the desired outcome. D4274 distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) This procedure is performed in an edentulous area adjacent to a periodontally involved tooth. Gingival incisions are utilized to allow removal of a tissue wedge to gain access and correct the underlying osseous defect and to permit close flap adaptation. When performed in conjunction with a gingival flap or osseous surgery procedure, it is considered part of that procedure and should not be reported separately. Non-Surgical Periodontal Service D4320 provisional splinting – intracoronal This is an interim stabilization of mobile teeth. A variety of methods and appliances may be employed for this purpose. Identify the teeth involved. D4321 provisional splinting – extracoronal See D4320 descriptor. D4341 periodontal scaling and root planing – four or more teeth This procedure involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. It is indicated for patients with periodontal disease and is therapeutic,


not prophylactic, in nature. Root planing is the definitive procedure designed for the removal of cementum and dentin that is rough and/or permeated by calculus or contaminated with toxins or microorganisms. Some soft tissue removal occurs. This procedure may be used as a definitive treatment in some stages of periodontal disease and/or as a part of pre-surgical procedures in others. These procedures are intended to be used for scaling and root planing, not for scaling alone, so there must be some loss of attachment. Otherwise, there is no exposed root surface to plane. Even if appropriate probing depths (usually ≥ 4mm) are present, if there is no attachment loss, root planing cannot be accomplished so codes D4341/D4342 should not be submitted for payment. Since only scaling is possible in those instances and there is no code for scaling, D1110 (Prophylaxis) is the appropriate code. When scaling is performed with definitive root planing on patients with periodontal disease, code D4341 should be reported. Whether provided as a definitive procedure or as a pre-surgical service, it should be reported by individual quadrants with dates of service. Any “extended appointment” services should be noted to justify the fee. To learn more read the Academy’s Policy Statement on Scaling and Root planing (http://www.perio.org/members/tpi/policy/policy12.html). D4342 periodontal scaling and root planing – one to three teeth per quadrant See descriptor D4341 D4355 full mouth debridement to allow comprehensive evaluation and diagnosis The gross removal of plaque and calculus that interfere with the ability of the dentist to perform a comprehensive oral evaluation. This preliminary procedure does not preclude the need for additional procedures. A healing period should be allowed before a comprehensive evaluation is done. That would be followed by any needed periodontal or other dental treatment. D4381 localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report FDA approved subgingival delivery devices containing antimicrobial medication(s) are inserted into periodontal pockets to suppress the pathogenic microbiota. These devices slowly release the pharmacological agents so they can remain at the intended site of action in a therapeutic concentration for a sufficient length of time. This procedure is utilized most often for teeth that have not responded to mechanical (either surgical or non-surgical) periodontal treatment or that exhibit recurrent periodontal disease. In some instances, it also is used during initial non-surgical therapy. See Academy’s Statement on Local Delivery of Sustained or Controlled Release Antimicrobials as Adjunctive Therapy in the Treatment of Periodontics (http://www.perio.org/resources-products/pdf/51-antimicrobials.pdf). D4910 periodontal maintenance This procedure is instituted following periodontal therapy and continues at varying intervals, determined by the clinical evaluation of the dentist, for the life of the dentition or any implant replacements. It includes removal of the bacterial plaque and calculus from supragingival and subgingival regions, site specific scaling and root planing where indicated, and polishing the teeth. If new or recurring periodontal disease appears, additional diagnostic and treatment procedures must be considered. Usually, three months between appointments is an effective schedule. Site-specific (one or two teeth per quadrant) periodontal scaling and root planing is included in this procedure. If more teeth require this additional treatment, D4341 or D4342 should be reported. Even though an evaluation is considered an integral part of periodontal maintenance, as stated in the AAP’s Parameters of Care (http://www.perio.org/resources-products/pdf/parameters.pdf), Position Paper (http://www.perio.org/resources-products/posppr3-3.html) and Policy Statement on periodontal maintenance (http://www.perio.org/members/tpi/policy/policy11.html), it no longer is included in this


code and, if performed, should be reported separately. D4999 unspecified periodontal procedure, by report Interim Prosthesis D5820 interim partial denture (maxillary) Includes any necessary clasps and rests. D5821 interim partial denture (mandibular) Includes any necessary clasps and rests. Other Removable Prostehtic Services D5867 replacement of replaceable part of semi-precision or precision attachment (male

or female component) Maxillofacial Prosthetics D5991 topical medicament carrier A custom fabricated carrier that covers the teeth and alveolar mucosa, or alveolar mucosa alone, and is used to deliver topical corticosteroids and similar effective medicaments for maximum sustained contact with the alveolar ridge and/or attached gingival tissues for the control and management of immunologically mediated vesiculobullous mucosal, chronic recurrent ulcerative, and other desquamative diseases of the gingiva and oral mucosa. It is not to be used for the treatment of periodontal diseases. D5992 adjust maxillofacial prosthetic appliance Implant Services Pre-Surgical Services D6190 radiographic/surgical implant index, by report An appliance, designed to relate osteotomy or fixture position to existing anatomic structures, to be utilized during radiographic exposure for treatment planning and/or during osteotomy creation for fixture installation. Surgical Services D6010 surgical placement of implant body, endosteal implant Includes second stage surgery and placement of healing cap.

D6012 surgical placement of interim implant body for transitional prosthesis, endosteal

implant Includes removal during later therapy to accommodate the definitive restoration, which may include placement of other implants. D6100 implant removal, by report This procedure involves the surgical removal of an implant. Describe procedure.


Implant Supported Prosthetics D6055 connecting bar – implant supported or abutment supported Utilized to stabilize and anchor a prosthesis. D6056 prefabricated abutment – includes placement A connection to an implant that is a manufactured component usually made of machined high noble metal, titanium, titianium alloy or ceramic. Modification of a prefabricated abutment may be necessary, and is accomplished by altering its shape using dental burrs/diamonds. D6057 custom abutment – includes placement A connection to an implant that is a fabricated component, usually by a laboratory, specific for an individual application. A custom abutment is typically fabricated using a casting process and usually is made of noble or high noble metal. A ‘UCLA abutment’ is an example of this type abutment. D6080 implant maintenance procedures, including removal of prosthesis, cleansing of

prosthesis and abutments and reinsertion of prosthesis This procedure includes a prophylaxis to provide active debriding of the implant and examination of all aspects of the implant system, including the occlusion and stability of the superstructure. The patient is also instructed in thorough daily cleansing of the implant. D6199 unspecified implant procedure, by report Use for procedure that is not adequately described by a code. Describe procedure. Other Periodontally-Related Services Extractions (Includes Local Anesthesia, Suturing, If Needed, And Routine Postoperative Care) D7140 extraction, erupted tooth or exposed root (elevation and/or forceps removal) Includes routine removal of tooth structure, minor smoothing of socket bone, and closure, as necessary. D7210 surgical removal of erupted tooth requiring removal of bone and/or sectioning

of tooth, and including elevation of mucoperiosteal flap if indicated Includes related cutting of gingiva and bone, removal of tooth structure, minor smoothing of socket bone and closure. Tooth removal during a periodontal surgical procedure should not be coded D7210 unless it would require elevation of a mucoperiosteal flap, removal of bone, and/or sectioning of the tooth if that periodontal procedure were not being done at the same time. D7220 removal of impacted tooth – soft tissue Occlusal surface of tooth covered by soft tissue; requires mucoperiosteal flap elevation. D7230 removal of impacted tooth – partially bony Part of crown covered by bone; requires mucoperiosteal flap elevation and bone removal. D7240 removal of impacted tooth – completely bony Most or all of crown covered by bone; requires mucoperiosteal flap elevation and bone removal. D7280 surgical access of an unerupted tooth An incision is made and tissue is reflected and bone removed as necessary to expose the crown of an impacted tooth not intended to be extracted. A subepithelial connective tissue graft (D4273) may be


required in conjunction with this procedure in order to provide an adequate zone of attached gingiva and should be reported using its own unique code. If adequate keratinized tissue is available, consideration should be given to use code D4265 instead of this code. D7283 placement of device to facilitate eruption of impacted tooth Placement of an orthodontic bracket, band or other device on an unerupted tooth, after its exposure, to aid in its eruption. Report the surgical exposure separately using D7280. . D7285 biopsy of oral tissue – hard (bone, tooth) For removal of specimen only. This code involves biopsy of osseous lesions and is not used for apicoectomy/periradicular surgery. Always attach a pathology report, when submitting a claim to either dental or medical insurance. D7286 biopsy of oral tissue - soft For surgical removal of an architecturally intact speciman only. This code is not used at the same time as codes for apicoectomy/periradicular curettage. Always attach a pathology report, when submitting a claim to either dental or medical insurance. D7287 exfoliative cytological sample collection For collection of non-transepithelial cytology sample via mild scraping of the oral mucosa. Oral pathology laboratory services should be reported separately by the laboratory providing the service. Always attach a pathology report, when submitting a claim to either dental or medical insurance. D7288 brush biopsy – transepithelial sample collection For collection of oral disaggregated transepithelial cells via a rotational brushing of the oral mucosa. Oral pathology laboratory services should be reported separately by the laboratory providing the service. . Always attach a pathology report, when submitting a claim to either dental or medical insurance. D7291 transseptal fiberotomy/supra crestal fiberotomy, by report The supraosseous connective tissue attachment is surgically severed around the involved teeth. Where there are adjacent teeth, the transseptal fiberotomy of a single tooth will involve a minimum of three teeth. Since the incisions are within the gingival sulcus and tissue and the root surface is not instrumented, this procedure heals by the reunion of connective tissue with the root surface on which viable periodontal tissue is present (reattachment). This procedure is used in conjunction with orthodontic treatment and may be subject to the orthodontic maximum allowance. D7292 surgical placement: temporary anchorage device {screw retained plate}

requiring surgical flap Insertion of a temporary skeletal anchorage device that is attached to the bone by screws and requires a surgical flap. Includes device removal. This code is used most often to provide anchorage for orthodontic appliances and may be subject to the orthodontic maximum allowance.

D7293 surgical placement: temporary anchorage device requiring surgical flap Insertion of a device for temporary skeletal anchorage when a surgical flap is required. Includes device removal. This code is used most often to provide anchorage for orthodontic appliances and may be subject to the orthodontic maximum allowance. D7294 surgical placement: temporary anchorage device without surgical flap Insertion of a device for temporary skeletal anchorage when a surgical flap is not required. Includes device removal. This code is used most often to provide anchorage for orthodontic appliances and may be subject to the orthodontic maximum allowance.


D7295 harvest of bone for use in autogenous grafting procedure Reported in addition to those autogenous graft placement procedures that do not include harvesting of bone. D7471 removal of lateral exotosis (maxilla or mandible) D7510 incision and drainage of abscess – intraoral soft tissue Involves incision through mucosa, including periodontal origins. D7950 osseous, osteoperiosoteal, or cartilage graft of the mandible or maxilla –

autogenous, by report This code may be used for ridge augmentationor reconstruction to increase height, width and/or volume or residual alveolar ridge. It includes obtaining autograft and/or allograft material. Placement of a barrier membrane, if used, should be reported separately. Since this is a “by report’ code, a narrative must accompany the claim. Notation also should be made that it is preparatory to implant placement, if applicable. D7951 sinus augmentation with bone or bone substitutes The augmentation of the sinus cavity to increase alveolar height for reconstruction of edentulous portions of the maxilla. This includes obtaining the bone or bone substitutes. Placement of a barrier membrane, if used, should be reported separately. This code includes both osteotome and lateral window interventions. Notation should be made that it may be in preparation for implant placement, if applicable. D7953 bone replacement graft for ridge preservation – per site Osseous autograft, allograft or non-osseous graft is placed in an extraction or implant removal site at the time of the extraction or removal to preserve ridge integrity (e.g., clinically indicated in preparation for implant reconstruction or where alveolar contour is critical to planned prosthetic reconstruction). Membrane, if used should be reported separately. Notation should be made that it may be in preparation for implant placement. This code is to be used when the graft is placed in an extraction site at the time of the extraction and placement of an implant or a prosthetic reconstruction is planned for a later date. It should not be used when an immediate implant is utilized. D7950 is the proper code for those procedures. D7960 frenulectomy – also known as frenectomy or frenotomy – separate procedure not incidental to another procedure Surgical removal or release of mucosal and muscle elements of a buccal, labial or lingual that is associated with a pathological condition, or interferes with proper oral development or treatment. This code should be used regardless of the location of the frenum. When performed in conjunction with a soft tissue graft,it is considered part of that procedure. D7963 frenuloplasty Excision of frenum with accompanying excision or repositioning of aberrant muscle and z-plasty or other local flap closure D7970 excision of hyperplastic tissue – per arch


D7971 excision of pericoronal gingiva Surgical removal of inflammatory or hypertrophied tissues surrounding partially erupted/impacted teeth. Unclassified Treatment D9110 palliative (emergency) treatment of dental pain – minor procedure This is typically reported on a “per visit” basis for emergency treatment of dental pain. This code should be used for relief of pain or swelling when no definitive treatment is performed. D9120 fixed partial denture sectioning Separation of one or more connections between abutments and/or pontics when some portion of a fixed prosthesis is to remain intact and serviceable following sectioning and extraction or other treatment. Includes all recontouring and polishing of retained portions. Anesthesia D9210 local anesthesia not in conjunction with operative or surgical procedures D9215 local anesthesia in conjunction with operative or surgical procedures D9230 inhalation of nitrous oxide/anxiolysis, analgesia Most commonly used when nitrous oxide/oxygen combination is administered. The level of anesthesia is determined by the anesthesia provider’s documentation of the anesthetic’s effects upon the central nervous system and not dependent upon the route of administration. D9241 intravenous conscious sedation/analgesia – first 30 minutes Anesthesia time begins when the doctor administering the anesthetic agent initiates the appropriate anesthesia and non-invasive monitoring protocol and remains in continuous attendance of the patient. Anesthesia services are considered completed when the patient may be safely left under the observation of trained personnel and the doctor may safely leave the room to attend to other patients or duties. D9242 intravenous conscious sedation – each additional 15 minutes

See descriptor D9241. D9248 non-intravenous conscious sedation A medically controlled state of depressed consciousness while maintaining the patient’s airway, protective reflexes and the ability to respond to stimulation or verbal commands. It includes non-intravenous administration of sedative and/or analgesic agent(s) and appropriate monitoring. ADA guidelines for administration of conscious sedation may be found at www.ada.org. Professional Visits D9430 office visit for observation (during regularly scheduled hours) – no other services performed D9440 office visit – after regularly scheduled hours


D9630 other drugs and/or medicaments, by report Includes, but is not limited to oral antibiotics, oral analgesics, and topical fluoride dispensed in the office for home use; does not include writing prescriptions. D9910 application of desensitizing medicament Includes in-office treatment for root sensitivity. Typically reported on a “per visit” basis for application of topical fluoride. This code is not to be used for bases, liners or adhesives used under restorations. D9920 Behavior management, by report May be reported in addition to treatment provided. Should be reported in 15-minute increments. D9930 treatment of complications (post-surgical) – unusual circumstances, by report For example, treatment of a dry socket following extraction or removal of bony sequestrum. D9940 occlusal guard, by report Removable dental appliances, which are designed to minimize the effects of bruxism (grinding) and other occlusal factors. D9942 repair and/or reline of occlusal guard D9951 occlusal adjustment – limited May also be known as equilibration, reshaping the occlusal surfaces of teeth to create harmonious contact relationships between the maxillary and mandibular teeth. Presently includes discing/odontoplasty/enamoplasty. Typically reported on a “per visit” basis. This should not be reported when the procedure only involves bite adjustment in the routine post-delivery care for a direct/indirect restoration or fixed/removable prosthodontics. D9952 occlusal adjustment – complete Occlusal adjustment may require several appointments of varying length, and sedation may be necessary to attain adequate relaxation of the musculature. Study casts mounted on an articulating instrument may be utilized for analysis of occlusal disharmony. It is designed to achieve functional relationships and masticatory efficiency in conjunction with restorative treatment, orthodontics, orthognathic surgery, or jaw trauma when indicated. Occlusal adjustment enhances the healing potential of tissues affected by the lesions of occlusal trauma. D9999 unspecified adjunctive procedure, by report Used for procedure that is not adequately described by a code. Describe procedure.


Section 4 Insurance Reporting Submitting a Claim Form The American Academy of Periodontology encourages the use of the current American Dental Association Dental Claim Form for paper claims. Electronic claims must be submitted using the HIPAA-standard claim (ANSI ASC X12N Transaction Set 837) and must be accepted by all third party payers. Click here for a copy of the Dental Claim Form or visit the ADA’s Web site for more information. In addition, it can be purchased from the ADA or from dental form suppliers. It also may be included in dental software packages. To facilitate accurate reporting and processing of claims for dental treatment, the Academy encourages use of the most recent version (CDT-2011) of the ADA’s Code on Dental Procedures and Nomenclature must be used. Use of an earlier version may result in the claim being denied or returned for correction by the carrier. To simplify reporting of services, dental claim forms can be preprinted to indicate the most commonly performed procedures. If the practitioner uses a superbill, it should include all the information found on the Dental Claim Form. Failure to do so can lead to delays in processing of claims. A completed superbill should be attached to the Dental Claim Form containing the necessary patient information and signatures. Forms provided to the patient by his/her carrier will be very similar to the ADA Dental Claim Form. Most government agencies such as Medicaid, accept the standard ADA Dental Claim Form, although some still may require their own forms. Medicare claims must be submitted on a medical form (CMS-1500). Use of the Dental Claim Form in lieu of forms provided by these agencies will result in undue delays in processing and may even result in non-payment of the claim. Section 36 of the Dental Claim Form authorizes release to the carrier of information relating to the claim. In that section, the patient also agrees “to be responsible for all charges for dental services and materials not paid by my dental benefit plan, unless the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges.” This statement becomes very important if a dispute over payment of fees arises between a third party carrier and a dentist. Box 1 on the Dental Claim Form should be completed to indicate whether the claim reports actual services or is a request for predetermination of benefits or both. Claims for periodontal services should include the following information: 1. A written diagnosis using the classification of periodontal diseases outlined in Section 1, including the extent and severity of the disease; 2. A list of the treatment(s) performed or planned, identified by proper code number. Appropriate codes and their descriptors may be obtained from Section 3 of this manual; 3. The actual or estimated fee for each procedure. Reasons for unusual fees (higher or lower) should be noted on the Dental Claim Form in Section 35 (Remarks) or attached to the form. This section also should be used for brief, patient-specific narratives to describe “by report” codes and to provide treatment rationales (e.g., crown lengthening, soft tissue grafts) when the dentist feels such information will aid in proper adjudication of the claim. Even though that is its purpose, some carriers’ data entry facilities are not able to transmit information contained in the Remarks section to consultants so it probably is better to attach the narrative to the paper claim form.


That should not be a problem though with electronic claims. All procedures should be reported and benefited as accurately as possible. Any significant variation from the therapy described by a code should be reported in Section 35 of the Dental Claim Form. If the third party payer changes a procedure code reported by a dentist, the Explanation of Benefits (EOB) should clearly note such change and explain the reasons for it.

Dentist’s Pretreatment Estimate Predetermination of benefits allows the patient to determine how much financial assistance he/she can expect from the dental plan for the proposed treatment. Some carriers do not predetermine benefits, while others require it. Failure to predetermine benefits when required can result in denial of payment by the carrier. As explained on page 13, predetermination of benefits is not an absolute commitment by a third party that the estimated payment will be made. A written predetermination of benefits should be returned to the dentist by the carrier indicating those services covered by the plan, the benefit provided for each service, and the total estimated financial responsibility of both patient and carrier, taking into account deductibles, coinsurance, and yearly maximum. Dentist’s Statement of Actual Services When submitting a claim for completed services, dates of treatment must be provided. This is essential because almost all plans have limitations relative to the effective date of coverage and annual maximum benefits. The patient must sign claim forms requesting payment of benefits to the dentist. Possession of a valid “signature on file” may be noted instead. The dentist also must sign the form certifying that the procedures have been completed. Following is a step-by-step explanation of what information should be included in “Record of Services Provided” (Sections 24-35) of the Dental Claim Form: 1. A written diagnosis using the classification of periodontal diseases outlined in Section 1 of this manual, including the extent and severity of the disease; 2. The dates of services, if the services have been provided (Section 24); 3. The area of the oral cavity and tooth numbers where the procedure was performed (Sections 25-28) 4. Current procedural codes to report the services to be performed (Sections 29-30); 5. The estimated or actual fee for each service performed (Section 31); 6. Missing teeth (Section 34); 7. “By report” procedures or procedures for which no adequate code is available should be described in the “Remarks” area (Section 35);


8. Certification that the procedures indicated by date are in progress (for procedures that require multiple visits) or have been completed (Section 53); 9. Indication of the Treating Provider Specialty (Section 56A), Periodontics should be noted as 1223P0300X. 10. NPI of the practice or treating dentists NPI if not incorporated (Section 54).

The dates of service are essential because of dental plan limitations relative to the effective date, eligibility, and annual and lifetime maximums of the coverage for the insured. Check List for Filing Dental Claim Forms 1. Is the form typed or printed legibly so that third party personnel can read and process the

information provided? 2. Are the “patient” and “dentist” sections completed accurately and completely, including employee

identification numbers, dates of birth, and information on the spouse for coordination of benefits? 3. Has the diagnosis been noted on the claim form? 4. Have all procedures been identified by ADA codes and properly related to dates of service and

fees? 5. Have the missing teeth been identified on the tooth chart? 6. Have “by report” procedures and unusual services been noted in Section 35 on the claim form or

described in more detail on a separate sheet? 7. Has notation been made regarding specialty status? 8. Has the patient signed and dated the claim form, or has a valid authorization/assignment form

been signed by the patient and has this been noted in the appropriate places as “signature on file?”

9. Has the insured person signed the form in the appropriate space in order for benefits to be paid directly to the dentist if so desired (assignment of benefits)?

10. Has notation been made regarding prior (financial) agreement with the patient? 11. Has the form been signed and dated by the dentist? 12. Has a copy been filed in the office records?


Transactions and Code Sets ADA Code on Dental Procedures and Nomenclature It is important to note that any dental practice that electronically sends or receives certain transactions must send or receive the information in a standard format. As of January 1, 2011, the standardized code set to submit is the ADA CDT-2011 for all dental claim submissions. Dental practices must be sure that the clearinghouse they are using is HIPAA compliant. It is important to ask whether these changes will be made as part of a maintenance contract or if there will be additional charges for the service. Another important point to note is that all dentists will still be able to submit paper claims to a benefit carrier; however, if you submit even a single electronic transaction, you must comply with HIPAA standards or possibly face fines for non-compliance. International Standards Organization System The ADA recognizes two major systems used for tooth numbering:

• Universal/National system which is used primarily in the United States • International Standards Organization System (ANSI/ADA/ISO Specification No. 3950 – 1984

Dentistry Designation System for Tooth and Areas of the Oral Cavity), which is used in many countries outside the USA. Utilization of these designation systems began in conjunction with the onset of HIPAA compliance regulations and became mandatory on October 16, 2003 for all electronic or paper claims submitted to a benefit carrier.

Under the Universal/National System, a number from 1 to 32 identifies each tooth in sequential order across both arches with 1 being the patient’s upper right third molar and 16 the upper left third molar. In the lower arch, 17 identifies the lower left third molar and 32 the patient’s lower right third molar. The International Standards Organization System (ANSI/ADA/ISO) identifies areas of the oral cavity as well as individual teeth and sextants.

00 Designates the whole area of the oral cavity 01 Designates the maxillary area 02 Designates the mandibular area 10 Designates the upper right quadrant 20 Designates the upper left quadrant 30 Designates the lower left quadrant 40 Designates the lower right quadrant Sextant designations should not be used for periodontal procedures, as they are based on single teeth or quadrants. The entirety of both designation systems can be found in the ADA’s CDT-2011. National Provider Identifier (NPI) Effective May 23, 2007, all dentists who use standard electronic transactions such as electronic claims, eligibility verifications, claims status inquiries, and claim attachments, even if they use billing services to prepare the transactions, must include their NPI on those transactions.


While not mandated by HIPAA, some health plans may require NPIs even on paper claims. Some states also may require use of an NPI on prescriptions even though federal law does not require their use.

• Once implemented throughout the health care industry, the same NPI will be accepted by all dental plans as a valid provider on all standard electronic transactions.

• A single NPI will identify each dentist regardless of office location. • Incorporated dentists or dentists billing under a partnership should obtain two NPI’s, one for

themselves and the other for the billing entity • Dental plans no longer can require arbitrary identifiers. • This standardization of electronic transactions should improve acceptance rates and speed their

processing. The National Provider Identifier does not

• Replace the DEA number used when prescribing controlled substances or other DEA-related activities.

• Replace state-issued licenses and certifications verifying a dentist’s licensing or qualifications. • Replace the Social Security Number (SSN), Tax Identification Number (TIN), or Employer

Identification Number (EID) for tax purposes. Additional information about NPIs may be obtained at https://nppes.cms.hhs.gov and at http://www.ada.org/2965.aspx?currentTab=1 , or by calling 1-800-465-3203. Dental Claim Examples Periodontal Maintenance Procedures (following active therapy) This procedure is for patients who have been previously treated for periodontal disease. Typically, maintenance starts after completion of active (surgical or non-surgical) periodontal therapy and continues for the life of the dentition. Since a periodontal evaluation no longer is a component of periodontal maintenance, it should be submitted either as a periodic oral evaluation (D0120) or as a comprehensive periodontal evaluation – new or established patient (D0180). A periodic oral evaluation includes periodontal screening (PSR or an equivalent) while a comprehensive periodontal evaluation consists of an evaluation and recording of periodontal conditions, probing and charting, evaluation and recording of the patient’s dental and medical histories, evaluation of potential periodontal-systemic interrelationships, occlusal examination, and a general health assessment. It may include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, occlusal relationships, and oral cancer screening. A comprehensive periodontal evaluation should be performed annually or when changes in the patient’s periodontal condition are noted. A periodic oral evaluation should be carried out at all other periodontal maintenance treatments. Completion date for the periodontal treatment should be notified on the claim form. Emergency Visit An example of a request for patient reimbursement for emergency care is presented below. By its nature, emergency care reimbursement cannot be predetermined. Only the date of service, services rendered, and the dentist’s signature are required. A description of the procedure performed may be helpful in benefits determination. It should be noted in Section 35 of the claim form that this is an emergency visit.


Supplemental Examples

Included are some examples of how to report more complex treatment plans for patients requiring significant periodontal and other dental treatment. Consultation among several dentists and perhaps one or more physicians would be needed and their specialties should be listed. In addition to the usual diagnostic tests, more extensive modalities would be required and should be enumerated. It would take considerable time to gather all this information (D0160 – detailed and extensive oral evaluation – problem focused, by report) and a significant amount of time to present it to the patient) (D9450 – case presentation, detailed and extensive treatment planning) So an informed decision could be made. The conditions requiring this evaluation and case presentation should be documented along with the treatment planned. Failing Implant A narrative report indicating the clinical findings, need for implant repair, and procedures planned should accompany the claim to aid in benefit determination. Multiple Treatment Needs A periodontal chart and X-rays should accompany the claim to aid in benefit determination. A narrative explaining the need for an occlusal guard also should be attached. The example below illustrates proper reporting of several quadrants of periodontal surgery along with treatment of localized osseous defects. Code D4261 should be used for the lower left osseous surgery since only three contiguous teeth were involved. It is used appropriately when the periodontal problem encompasses less than four teeth or bounded tooth spaces in a quadrant and it should be reported in addition to any regenerative procedures that are performed. (Note D4263, D4264, D4265, D4266 and D4267 require tooth numbers). Extraction to be Followed by Single tooth Implant The upper right central incisor has a hopeless prognosis. It will be extracted and replaced with a single tooth implant after healing of the bone replacement graft to preserve ridge integrity. Since D7953 is done on the date of extraction in anticipation of future implant placement, no date for implant placement should be noted. Thus the claim also serves as a request for predetermination of benefits for that procedure and indicates to the carrier that an implant replacement is planned. Connective Tissue and Free Gingival Grafts A periodontal chart or short narrative describing the clinical findings should accompany the claim to aid in benefits determination. These should include the amounts of gingival recession and attached gingiva, presence of gingival inflammation, progression of recession, abnormal frenulum insertion, cervical caries or abrasion, and other findings. If a soft tissue allograft is used, the material also should be listed. Soft tissue defects can occur in areas with minimal pocket depth and are generally localized to facial or lingual tooth surfaces with little or no interproximal bone loss. Therefore, pocket depth measurements and radiographs have no diagnostic value in documenting the need for treatment. Clinical Crown Lengthening – Hard Tissue Below is a request for payment of benefits for clinical crown lengthening to allow a restorative procedure or a crown when little or no tooth structure is exposed to the oral cavity. In order to maintain periodontal health following restoration of the tooth, adequate (3 mm or more) tooth structure must be exposed. Even though adjacent teeth must be included in the procedure, list only the tooth or teeth requiring crown lengthening. This code is not to be used when enlarged gingival tissue and supporting bone (ostectomy) are removed to provide an anatomically correct gingival relationship in an otherwise periodontally healthy area.


The appropriate codes for those procedures are D4230 and D4231, (anatomical crown exposure) depending on the number of contiguous teeth treated. If supporting bone is not removed, the appropriate codes are D4210 and D4211 (gingivectomy or gingivoplasty). Cone Beam CT Multiple teeth in the lower left were removed several years ago. Since the patient could not tolerate a unilateral free end saddle removable partial denture, he now wishes to replace them with implants. The periodontist is unsure whether there is adequate bone for placement of implants and of the location of the mandibular nerve. A cone beam computerized tomograph captures information on ridge width and angulation and the distance to the inferior alveolar canal. This information then is utilized for a three dimensional image reconstruction for planning of implant placement. Ridge Augmentation The patient has been missing tooth number 20 for many years with resultant bone resorption. The adjacent teeth are sound and do not require restorations, so a single tooth implant is planned to replace number 20. There is inadequate height and width of alveolar bone to allow placement of the implant. Ridge augmentation is needed in order to increase the volume of the residual ridge and allow implant placement. Predetermination of Benefits The patient is missing all upper right molars. All other maxillary teeth, except the upper left third molar, are present. There is inadequate vertical bone height to place implants without impinging upon the maxillary sinus, so a sinus lift procedure is needed. This will provide adequate room to replace the upper right molars with implants as the patient and the dentist feel a unilateral free end removable partial denture would not be acceptable. Before beginning this course of treatment, the patient wants to determine her financial liability. Even though a predetermination estimate is not a guarantee of payment, it may be helpful for the patient to have an overall estimate of what their responsibility may be.


HIPAA’s Impact on Dentistry The Health Insurance Portability and Accountability Act (HIPAA) of 1996 required the U.S. Department of Health and Human Services to adopt national standards for electronic submission of all electronic administrative and financial health care transactions. These standards apply to all providers of health care and clearinghouses who utilize electronic health care transactions, either directly or through a third party. Any dentist who uses, or has ever used, standard electronic transactions such as electronic claims, eligibility verifications, claims status inquiries, and claims attachments is considered a covered entity by HIPAA. Dentists who use only paper, telephone, and fax to transmit this information are not subject to HIPAA regulations. These mediums require that insurance carriers exercise reasonable or meaningful caution in protecting PHI (Private Health Information). The Department of Health and Human Services (HHS) has issued regulations requiring health care providers, health plans, and other entities covered by the Health Insurance Portability and Accountability Act (HIPAA) to notify individuals when their health information has been breached. These “breach notification” regulations implement provisions of the Health Information Technology for Economic and Clinical Health (HITECH) Act, passed as part of the American Recovery and Reinvestment Act of 2009 (ARRA). This new federal law ensures that covered entities and business associates are accountable to the Department and to individuals for proper safeguarding of the private information entrusted to their care. The HITECH Breach Notification Rule requires a covered entity to notify affected individuals of incidents like stolen laptops, break-ins with theft of computer hardware or removable media, “missing” hard drives, etc. that may impact the privacy of their information, with two exceptions: The first exception occurs when the information was verifiably destroyed in some manner. The date of destruction and method used need to be recorded; the method of destruction must render the information beyond use. The second exception is when the data is encrypted according to methods described by certain National Institute of Standards and Technology (NIST) publications.) Encryption is a technique for transforming information in such a way that it becomes unreadable by unauthorized people. If an unauthorized person is able to gain access to a computer containing PHI, he or she will not be able to read or interpret that information so the patient’s privacy will be protected. Encryption is done either by computer programs or by specially designed computer hardware devices which apply a mathematical algorithm (a recipe for producing encrypted data) to the information. The output is a scrambled form of the original data. When a legitimate user needs to access the data, the scrambling process is reversed (decrypted), and the data is restored to its original form. The HITECH approved encryption standards are available at: http://www.csrc.nist.gov/. The ADA’s HIPAA Compliance for Privavcy and Security Kit may be purchased at www.ADAcatalogue.org, or by calling 800/947-4746. HIPAA requires dentists to submit and payers to accept electronic claims in the standard format, but it does not require dentists to submit claims electronically. Paper claims still must be accepted by third parties. At some point, though, many carriers probably will offer incentives for use of electronic claims or


disincentives for use of paper. In what may be a precursor of things to come, Minnesota now requires that all health care providers and insurance carriers send and accept electronic transactions. Minnesota is setting these standards because in health care, as in other industries, administrative costs are reduced and productivity increased when transactions are processed electronically using common formats and conventions. It is expected that the new law will accelerate the use of standard, electronic transactions to help reduce health care administrative costs and related “hassle factor”. This law applies to all dentists, physicians, hospitals, pharmacists, chiropractors, and personal care attendants. In 2008, 52.06 percent of all dental claims were submitted electronically according to a survey conducted by the National Dental Electronic Data Interchange Council (NDEDIC). That percentage increased to 56.68 percent in 2009 and is projected to continue to grow. Although some third parties accept electronic claims directly from dental offices, most are submitted via a clearinghouse. Depending on the office’s practice management software, claims are sent either directly to the clearinghouse or to the practice management software vendor who then transmits them to the clearinghouse. If the clearinghouse receives the claims from PMS vendors, the transactions should have been screened for edits PRIOR to being sent to the clearinghouse. The PMS vendor detects edits and communicates with the dental office so that they can resolve any edits before being sent to the clearinghouse. It could get very expensive for the dental office very fast if claims are sent by the PMS vendor to the clearinghouse for editing. Once the clearinghouse receives the claim, they charge the PMS vendor that sent it. If the clearinghouse checks and finds edits on the claim, it must be sent back to the dental office for resolution. When the edits are resolved and transmitted again, there is another charge for the same claim (s) once they reach the clearinghouse. Typically, there is no charge for editing the claim between the dental office and the PMS vendor. This process allows only ‘clean’ claims to be sent to the clearinghouse to then be sent to the insurance carrier. There is a charge for each claim submitted, but claims can contain an almost unlimited number of line items. Electronic submission of claims eliminates postage costs and reduces the clerical effort and paperwork involved with insurance forms in the periodontal office. It also provides a shorter turn-around time for claims payment and pretreatment estimates. Many practice management software programs allow on-line, real-time patient eligibility, coinsurance, deductible, and remaining yearly maximum information to be obtained from the carrier. Capability for direct deposit of benefits exists, but few carriers or dental offices utilize it yet despite the inherent cost savings. Electronic claims submission and processing reduces clerical errors in third party and periodontal offices. Claims sent by the dental office are subject to “edit checks” in the software program and by the clearinghouse. This improved accuracy also lowers claims processing costs for both the dental office and the carrier. A major drawback to increased use of electronic claims by periodontists has been the need of many carriers for documentation of clinical conditions. Fortunately, documentation now can be submitted to third party carriers over the Internet at a modest cost to the dental office. Acceptance of these attachments by carriers is mandated by HIPAA. The American Dental Association Specification 1047 for Standard Content of an Electronic Periodontal Attachment was approved on June 12, 2006 as an American National Standard by the American National Standards Institute (ANSI). While acceptance of this Standard by all carriers and dentists at this time is not mandatory, it is anticipated that its adoption will help alleviate many of the obstacles to electronic claims submission for periodontal procedures. The x-rays, narratives, and other pertinent information also can be transmitted to referring dentists who are equipped to receive it.


Several companies and dental software providers are able to transmit this documentation. Their systems differ in how they do so, but all link the documentation with the electronically submitted claim. The chart, x-rays, narratives, etc. are available for review by a dental consultant. They do not get lost in the mail or become separated from a paper claim in the carrier’s office so there should be no repeat requests for submitted documentation. Turnaround time should improve and staff time and expenses should be reduced. The technical requirements for submission of claims and documentation differ slightly among the various providers of these services so it is best to obtain them directly from those sources. Each company has an initial setup fee covering software, installation, and training as well as a monthly fee for an unlimited number of transactions or a fee for each submission. Electronic claims are submitted to a clearinghouse or directly to a carrier in the usual way. When documentation is required, it is submitted first and a reference number is returned immediately. That number then is entered in the “Remarks” section of the electronic claim form. The dental consultant can access the images when the claim is reviewed. Depending upon how the documentation was transmitted, the referring dentist or other specialists involved in the care of the patient may also be able to access the information. Documentation must be transmitted to carriers and to other dentists utilizing a secured connection in accordance with HIPAA privacy regulations. Also, these are two separate processes. E-claims are sent via a PMS vendor, clearinghouse or directly to the insurance carrier. E-attachments use a different vendor for the transmission of attachments. Prior to purchasing a system few pertinent questions should be asked of dental management software vendors concerning their electronic claims processing component:

1. What are the hardware and software requirements for electronic dental claims processing? 2. Can related and subsequently upgraded software packages be added to the system without further

hardware upgrades? Can these programs be integrated with electronic claims processing to satisfy other payer needs for further documentation?

3. What are the direct costs associated with electronic claims processing; i.e., is there an annual fee, per claim charge, or volume based charge?

4. Does the clearinghouse have direct access to payers? Which ones? How does this relate to the payers who represent the bulk of the insured patients in a particular periodontal practice?

5. When enhanced services are available, will the vendor and/or clearinghouse be able to provide these services and at what cost; i.e., on-line real time eligibility status, on-line real time claim status, on-line remittance advice, and ultimately direct electronic funds transfer?

6. What is the expected turn-around time for a claim? For a predetermination? 7. Is the system capable of transmitting charts, X-rays, and narratives electronically?

Further information about electronic claims submission and how to get started may be obtained from the Clinical Affairs Manager at the AAP Central Office at [email protected], or from the National Dental Electronic Data Interchange Council (NDEDIC) at 602/266-7740. Electronic Health Record (EHR) In 2004, as a result of an executive order by the Bush administration, a strategy for health IT implementation was established. These EHRs are defined as health-related information for an individual that conforms to nationally recognized interoperability standards and can be created, managed and consulted by authorized clinicians and staff across more than one health care organization.


Interoperability is the ability of two systems to exchange information, and to use the information that has been exchanged. The importance of this is to enable coordinated services among care providers and the systems supporting these providers. In April 2005 the ADA Board of Trustees established the NHII Task Force (National Health Information Infrastructure) to recommend strategic direction and policy regarding the ADA’s position in the NHII on the dental components of the electronic health record. In June 2007 the ADA Board of Trustees dissolved the NHII Task Force, and established an EHR workgroup, which was responsible to begin development and implementation of the dental components of the electronic health record. Costs for the implementation will vary based upon the level of electronic adoption already in place, as many practitioners are using electronic and digital data within their practice systems. Also, the size of the practice and training of staff members will also affect the total cost. Estimates range from $20,000 up to $100,000, depending upon the size and demands of the practice. Some anticipated benefits to the EHR are improving care and making health care delivery more efficient and safer. Also, by bringing the electronic health records directly into the clinical practice it is expected to reduce medical errors, and avoid redundant testing and treatment, and to provide an opportunity for clinicians to focus on improved patient care. This will also allow the electronic transfer of accurate information which will be able to move with patients from one point of care to another. One of the most important factors is the privacy and security of health information. In September 2009, the Health IT Standards Committee endorsed a set of security and privacy standards for the electronic health record, which probably will be incorporated into certification criteria for compliant systems. The goal of an interoperable electronic health record is set at this time for 2014, and the recent push by the Obama administration for adoption of health IT as a significant means to achieve health care reform is likely to promote adherence to that time frame. The laws and regulations governing the sharing of electronic health information are still evolving. The ADA’s Advocacy Advisory Group, under the oversight of the ADA HER Workgroup and the ADA Council on Government Affairs, will monitor the legal requirements and regulatory activity for the appropriate implementation of the EHR in dentistry, and keep the membership informed as regulations are released. Electronic Submissions Version 4010/5010 When filing claims electronically, Version 4010 is the standard implementation guide; this version is currently mandated by HIPAA. In order to be compliant with HIPAA requirements, any dentist who transmits health information in an electronic transaction is required to do so via software that uses the standard 4010. However, with implementation guides for transactions continually undergoing periodic updates, Version 4010 is widely recognized as outdated and lacking certain functionality needed for the health care industry, so it will be replaced by Version 5010 in 2012. The new version 5010 includes structural, technical, and data content improvements that are more specific in calling for the data that is needed, collected, and transmitted in an electronic transaction.


Version 5010 would also accommodate the use of the International Classification of Diseases, Tenth Revision (ICD-10-CM) code sets, which are not supported by Version 4010 and which will be mandated in 2013. The compliance date for the 5010 HIPAA transactions is January 1, 2012. ICD-10-CM ICD-10-CM diagnosis codes have a compliance date of October 1, 2013. This change has occurred because there is no room in its current numeric system for additional ICD-9-CM codes. ICD-10-CM will allow for more codes but also for greater specificity in submissions, allowing providers to better identify certain patients with specific conditions. ICD-10-CM codes are very different from those currently used in ICD-9-CM. All codes in ICD-10-CM are alpha-numeric. There may be up to seven alpha-numeric characters, requiring billing software program changes to accommodate the additional digits. ICD-10-CM codes will be able to provide more in depth information about the patient’s condition that can be more easily captured in an electronic medical record. SNODENT Update SNODENT is the acronym given to the Systemized Nomenclature of Dentistry. SNODENT was developed by the ADA as a diagnostic code set for use in the electronic health and dental records environment. This is formatted on the Systemized Nomenclature of Medicine Clinical Terms (SNOMED-CT). New federal HIT certification criteria name SNOMED-CT as one of the vocabularies required for certified EHR systems. Due to an increased focus on the development of EHRs at the national level, in April 2007, the ADA Board of Trustees established a nine-member SNODENT Editorial Panel charged with reviewing and maintaining the clinical descriptors of SNODENT. In 2009, the Board of Trustees dissolved the Editorial Panel and, based on the Council on Dental Benefit Programs (CDBP) Bylaws authority, assigned responsibility for SNODENT to it. The SNODENT Committee has reviewed concepts that were no longer valid and needed to be retired from the original version of SNODENT. In addition, terms that were not otherwise specified (NOS) were removed and missing concepts were added. Also, a new numbering system was initiated, and a cross-walk/mapping of SNODENT to ICD-9 was developed. There are approximately 6,000 SNODENT concepts of which 450 are unique to SNODENT (i.e. not contained in SNOMED-CT). At this time, it is being beta tested at various organizations including Dental Schools, the Veterans Administration, Indian Health Service, large group practices and vendors. The mapping of SNODENT-to-ICD-9 is complete and SNODENT will eventually be mapped to-ICD-10. The ADA has been actively developing standards related to the dental electronic health records (EHR), and vocabularies specifically applicable to dentistry (procedural, diagnostic, dental laboratory and administrative). Also, dental quality measures are being developed in conjunction with the Centers for Medicare and Medicaid Services (CMS) through the Dental Quality Alliance (DQA). Use of Medical Codes Patients often request that periodontal services be reported to their medical insurance carrier, particularly when no dental benefits are available. Most medical plans have no annual maximum or it is many times greater than that of the dental plan so benefits are perceived to be much greater, but the deductible under the medical plan may be several thousand dollars rather than the lower amounts typically seen in dental plans. In addition, some dental benefit contracts require that periodontal surgical claims be submitted to the medical plan before they are adjudicated by the dental plan.


Submission of claims for dental services to both medical and dental carriers is neither illegal nor unethical provided both are aware of the existence of the other. When submitting to medical insurance utilize Current Procedural Terminology (CPT) codes whenever possible. Also, if submitting a medical claim you can call the AAP Clinical Affairs Manager for assistance (This guidance is not a substitute for CPT , HCPCS or ICD-9 medical coding systems, therefore the Academy cannot be held responsible for any misuse or misinterpretation of the information provided) in finding appropriate CPT codes at 800/282-4867 ext. 3241. When there is no appropriate CPT code, the American Dental Association Current Dental Terminology (CDT) code is used. The ADA CDT codes are classified as part of the Healthcare Common Procedure Coding System (HCPCS) Level II code set and are to be used as the standardized coding system for describing and identifying dental services that are not identified by AMA CPT codes. These procedure codes, without narrative descriptors, should be listed in Section 24D of the CMS-1500 claim form. While these HIPAA regulations apply only to electronic transmissions, almost all carriers also apply them to paper claims in order to simplify their administrative processes. The Department of Health and Human Services has an agreement with ADA to include CDT codes for use in billing for dental services. Inappropriate use of CPT codes to report dental procedures to the patient’s medical carrier or omission of pertinent facts about other coverage is illegal and unethical. If the patient also has dental coverage, the medical carrier must be made aware of its existence. When some periodontal procedures are covered under the patient’s medical plan, claims may be filed concurrently with dental and medical carriers so long as both are made aware of the other coverage and all information is accurate. Medical claims must be submitted using the standard CMS-1500 form. The form and instructions for its completion may be obtained at the National Uniform Claim Committee web site, at www.nucc.org. Since diagnostic codes, not procedure codes, drive reimbursement, ICD-9-CM diagnostic codes must be entered in Item 21. Up to four diagnoses may be entered and must be related to the lines of service in Item 24E by line number, using the highest level of specificity. Do not provide a narrative description in this field. See a template to use when submitting to a medical carrier, at www.perio.org/members/tpi/cpt/MedicalNecessity.pdf. A number of periodontal diagnostic codes appear in the current edition of the International Classification of Diseases (ICD-9-CM). Relevant medical conditions such as diabetes and cardiovascular disease also can be entered on theses lines if applicable. Below is a listing of ICD-9-CM Diagnosis Codes related to periodontal conditions. Disorders of tooth development and eruption 520.0 – Anodontia Absence of teeth (complete), (congenital) and (partial) 520.6 – Disturbances in tooth eruption Teeth embedded, impacted Other specific diseases of hard tissues of teeth 521.81 – Cracked tooth 873.63 – Tooth (broken) (fractured) (due to trauma) 522.5 – Periapical abscess without sinus


Abscess: Dental Dentoalveolar 522.7 – Periapical abscess with sinus Fistula: Alveolar process Dental Gingival and periodontal diseases 523.00 – Acute gingivitis, plaque induced 523.01 – Acute gingivitis, non-plaque induced 523.10 – Chronic gingivitis, plaque induced 523.11 – Chronic gingivitis, non-plaque induced Gingival recession 523.20 – Gingival recession, unspecified (narrative needed) 523.21 – Gingival recession, minimal 523.22 – Gingival recession, moderate 523.23 – Gingival recession, severe 523.24 – Gingival recession, localized 523.25 – Gingival recession, generalized Aggressive and acute periodontitis 523.30 – Aggressive periodontitis, unspecified (narrative needed) 523.31 – Aggressive periodontitis, localized 523.32 – Aggressive periodontitis, generalized 523.33 – Aggressive periodontitis Chronic periodontitis 523.40 – Chronic periodontitis, unspecified (narrative needed) 523.41 – Chronic periodontitis, localized 523.42 – Chronic periodontitis, generalized 523.6 – Accretions on teeth Dental calculus: subgingival supragingival Major anomalies of jaw size 524.01 – Maxillary hyperplasia 524.02 – Mandibular hyperplasia


Anomalies of tooth position of fully erupted teeth 524.30 – Unspecified anomaly of tooth position Diastema of teeth Displacement of teeth Transposition of teeth 524.31 – Crowding of teeth 524.32 – Excessive spacing of teeth Other Diseases and Conditions of the Teeth and Supporting Structures 525.11 – Loss of teeth due to trauma 525.12 – Loss of teeth due to periodontal disease 525.13 – Loss of teeth due to caries 525.19 – Other loss of teeth (narrative needed) Atrophy of edentulous alveolar ridge 525.21 – Minimal atrophy of the mandible 525.22 – Moderate atrophy of the mandible 525.23 – Severe atrophy of the mandible 525.24 – Minimal atrophy of the maxilla 525.25 – Moderate atrophy of the maxilla 525.26 – Severe atrophy of the maxilla Partial edentulism 525.51 – Partial edentulism, class I 525.52 – Partial edentulism, class II 525.53 – Partial edentulism, class III 525.54 – Partial edentulism, class IV Endosseous dental implant failure 525.71 – Ossesintegration failure of dental implant Due to: Complications of systemic disease, and infection 525.72 – Post-osseointegration biological failure of dental implant Due to: Lack of attached gingiva, and occlusal trauma Additional Endosseous Implant Failure Codes 525.73 – Post-osseointegration mechanical failure of dental implant Due to: Failure of dental prosthesis, fracture of dental implant


525.79 – Other endosseous implant failure (narrative needed) Due to; Dental implant failure 525.8 – Other specified disorders of the teeth and supporting structuresEnlargement of alveolar ridge Irregular alveolar process 526.81 – Exostosis of jaw Torus mandibularis Torus palatinus CPT Medical Procedure Codes CPT copyright 2011 American Medical Association. All rights reserved. 41800 – Drainage of abscess, cyst, hematoma from dentoalveolar structures 41820 – Gingivectomy – excision gingiva, each quadrant 40819 – Excision of frenum, labial or buccal (frenumectomy, frenulectomy, frenectomy) 41115 – Excision of lingual frenum 41828 – Excision of hyperplastic alveolar mucosa, each quadrant (specify) 41870 – Periodontal mucosal grafting 41872 – Gingivoplasty, each quadrant (specify) 21210 – Graft, bone; nasal, maxillary or malar areas (includes obtaining graft) 21215 – Graft, mandible (includes obtaining graft) 70300 – Radiologic examination, teeth; single view 70310 – Radiologic examination, teeth; partial examination, less than full mouth 70320 – Radilogic examination, teeth; complete, full mouth 70355 – Orthopantogram 70486 – Computed tomography, maxillofacial area; without contrast material 76376 – 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image post processing or an independent workstation. 21248 – Reconstruction of mandible, or maxilla endosteal implant, partial 21249 – Reconstruction of mandible, or maxilla endosteal implant, complete


41822 – Excision of fibrous tuberosities dentoalveolar structure 99144 – Moderate sedation services first 30 minutes 99145 – Each additional 15 minutes 40808 – Biopsy, vestibule of mouth 11100 – Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure) unless otherwise listed; single lesion 21031 – Excision of torus mandibularis 21032 – Excision of maxillary torus palatines 0232T – (new code effective 7/1/10) Injection(s) platelet rich plasma, any tissue, including image guidance, harvesting and preparation when performed.


CPT Evaluation Codes Here is a description in how to utilize the CPT Evaluation Codes:

• New – Patient referred by another patient or has been away from the practice for more than 2 years.

• Established – Patient with an ongoing relationship with the practice. • Referred – Referred by an MD, DDS, or any other medical entity.

All exams and consults start with the numbers “992_” FOURTH digit reflects the origin of the patient:

• 0 = New • 1 = Established • 4 = Referred

New Patient – 99201-99205 Established Patient – 99211-99215 Referred Patient – 99241-99245 FIFTH digit reflects the LEVEL of Difficulty, NUMBER of Areas involved, and the TIME it takes to make a Diagnosis:

• 1 = brief, simple • 2 = expanded • 3 = detailed • 4 = comprehensive • 5 = extensive, difficult

BRIEF EXAM – last digit is a “1”

• Single site, simple problem • Easy to diagnose • New patient – 99201 • Established patient – 99211 • Referred patient – 99241

EXPANDED EXAM – last digit is a “2”

• Several sites, same problem • Straightforward diagnosis • New patient – 99202 • Established patient – 99212 • Referred patient – 99242


DETAILED EXAM – last digit is a “3”

• Several sites, different problems • More involved examination i.e., chronic periodontitis, missing teeth • New patient – 99203 • Established patient – 99213 • Referred patient – 99243

COMPREHENSIVE EXAM – last digit is a “4”

• Multiple sites, many problem areas • May have medical issues also i.e.; fractured restorations/teeth, missing teeth, periodontal issues,

etc. • New patient – 99204 • Established patient – 99214 • Referred patient – 99244

EXTENSIVE EXAM – last digit is a “5”

• Multiple sites of traumatic injury or very complicated diagnosis w/wo medical issues • New patient – 99205 • Established patient – 99215 • Referred patient – 99245

E CODES Purpose: To report external factor that caused patient’s condition

• Secondary codes • Injury, trauma, adverse reaction to therapeutic drug • No effect on reimbursement level

V CODES Purpose: To validate a diagnosis. To report a condition affecting patient’s health status.

• Secondary codes MODIFIERS To alter the procedure code without changing the definition of a procedure

• Attach to procedure code with a hyphen LIST OF MODIFIERS

• -22 Increased procedural services – When the work required to provide a service is substantially greater than typically required


• -25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service

• -47 Anesthesia by surgeon (added to MAIN surgical procedure code)

• -50 Bilateral procedure (same procedure done on both sides of the same jaw)

• -51 Multiple procedures

• -52 Reduced services, procedure performed was less involved than the CPT code description

(used with bone graft code 21210/21215)

• -59 Main procedure, different site


Section 5 Medicare Medicare is the federally sponsored program under the Social Security Act that provides hospital benefits, medical care, and catastrophic coverage to elderly and disabled patients. Part A covers hospital services while Part B covers outpatient care. The program is administered by the Centers for Medicare and Medicaid Services (CMS). Medicare does not cover most routine dental services and will not pay for non-covered services. Medicare specifically excludes “services in conjunction with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth.” This includes the periodontium – gingiva, dentogingival junction, periodontal membrane, cementum, and alveolar bone. Medicare-covered services that are within the scope of practice (as defined by the states) of a physician as well as a dentist (an individual with a DDS or DMD degree who is licensed by his/her state to practice dentistry) are covered when provided by a dentist. Biopsies (including the brush biopsy) are the most frequently covered dental procedures. It is helpful to attach the pathology report to the Medicare claim. Inpatient oral examinations are covered under Part A prior to renal (and some other organ) transplant surgery. The 2003 Medicare Prescription Drug, Improvement and Modernization Act allows a dentist to “opt out” of Medicare for renewable two-year periods (Section 603 of Public Law 108-173). In order to “opt out,” the dentist must submit an affidavit to the carrier(s) administering Medicare claims in his/her state within 10 days of signing the first private contract. This affidavit notifies the carrier(s) that he/she will provide services to Medicare beneficiaries, except for emergency care or urgent care, only through private contracts with those patients; submit no Medicare claims (again except for emergency and urgent care services); and accept no reimbursement from Medicare. Each Medicare-eligible patient must sign the private contract before treatment is begun. The patient needs to sign only one contract during each two-year “opt out” period covered by the affidavit. The contract provides that the patient agrees to give up Medicare payment for services by the dentist and agrees to pay the dentist in full without regard to any Medicare payment limits. The contract must contain certain specified items and be written in “sufficiently large” print to ensure the patient is able to read it. Sample affidavits and private contracts may be downloaded from the Members Only section of the ADA Web site at www.ada.org. A link to this site is provided through the Academy’s Web site www.perio.org. Advanced Beneficiary Notice (ABN) Any dental practice that has not formally opted out of Medicare should provide each patient over 65 with an ABN for services that they know are excluded or may not be covered under Medicare. That way, if a patient requires you to submit a claim to Medicare (and they can legally demand that you do so), you are protected from having to write off the cost of treatment simply because the patient had not been given an ABN. When filing a claim to Medicare (on a CMS-1500 claim form) for a procedure in which the patient was issued an ABN, the modifier “GA” should be submitted at the end of the procedure code (CPT/HCPCS). This shows that the patient has acknowledged that Medicare may not approve the services and agrees to pay for the service if it is denied. If a service is denied and the GA modifier is not included on the claim, Medicare’s EOB may state that the patient is not responsible for the charges and instruct the dentist to write off the fee. Effective March 1, 2009, Medicare requires providers to use its revised ABN, Form CMS-R-131. (Insert ABN instructions and form link) Medicare Modifiers


• GA – The GA modifier is reported in addition to the CPT/HCPCS code on a Medicare claim to

indicate that the provider expects that Medicare may deny the service, and an Advance Beneficiary Notice of non-coverage (ABN) has been signed by the patient and is on file. [

• GY – The GY modifier is reported in addition to the CPT/HCPCS code on a Medicare claim to show

that the item or service is statutorily excluded or does not meet the definition of any Medicare benefit. This should be used when a Medicare patient insists that a statutorily excluded dental service be submitted to Medicare. Virtually all dental care falls into this category.

• GZ – The GZ modifier is reported in addition to the CPT/HCPCS code on a Medicare claim to show that the patient has refused to sign the Advanced Beneficiary Notice on non coverage (ABN), and the provider expects the service to be denied by Medicare.

• GJ – The GJ modifier is reported in addition to the CPT/HCPCS code on a Medicare claim to indicate that an opt-out provider is submitting a claim for services that were performed in an emergency or urgent care situation.

To help explain the limited dental coverage available under Medicare, an “Advance Notice to People with Medicare” and a sample letter to patients have been developed by the American Dental Association and may be downloaded from their Web site. Dentists who do not “opt out” of the Medicare program have certain obligations even if they are not enrolled as a Medicare provider or do not wish to submit Medicare claims. The law provides that these dentists must submit an electronic or paper claim for Medicare-eligible patients when requested to do so even if the services provided are not covered by Medicare. Failure to do so may result in no patient liability for treatment and subject the dentist to fines and exclusion from federally funded programs such as Medicare and Medicaid. Another provision (Section 950) of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 bars carriers from requiring a Medicare denial for non-covered (by Medicare) dental services before adjudicating a claim. Some carriers had required such a denial before processing a claim for dental treatment. The complete text of the regulations may be found at http://www.hspm.com/health/Medicare_Conf_Agree.pdf on page 352. In order to bill Medicare, the dentist must have a Medicare provider number and submit the appropriate HIPAA-compliant diagnostic and procedure codes on a CMS-1500 claim form. Dentists in Alaska, Arizona, Colorado, Hawaii, Iowa, Minnesota, Nevada, North Dakota, South Dakota, Oregon, Washington, and Wyoming can call 1-877/908-8431. Dentists in all other states call 1-800-MEDICARE (1-800/633-4227) or go to www.medicare.gov. Medicare Participation Medicare participating providers sign a one-year contract (automatically renewed unless termination is requested by either party) and agree in advance to accept assignment on all Medicare patients they treat. Dentists who choose not to participate can still accept assignment on individual claims. In either case, Medicare imposes a reimbursement limitation. Reimbursement to non-participating dentists and physicians who have not ‘opted out” is limited to 115% of the Medicare allowable charge. They will be paid by the patient who then will be reimbursed by Medicare for its percentage of the maximum allowable charge.


The bottom line is that you can retroactively enroll in Medicare after treatment has been performed on a Medicare patient, but you cannot retroactively furnish the ABN. The ABN must be provided before services are rendered. Medicare Resources Centers for Medicare and Medicaid Services (CMS) www.cms.gov 1-800/MEDICARE (1-800/633-4227) American Dental Association Council on Dental Benefits 1-800/621-8099 www.ada.org


CMS-1500 Medical Claim Form Instructions (Copy of Medical claim form at nucc.org) Item 1: Show the type of health insurance coverage applicable to the claim by checking the appropriate box. (Do not use dashes in number. Be sure to add the letter suffix.) Item 1a: Enter the patient’s Health Insurance Claim Number (Do not use hyphens or spaces as separators within the ID Number) Item 2: Enter the patient’s last name, first name, and middle initial, if any, as shown on the patient’s card. This is a required field. Item 3: Enter the patient’s 8-digit birth date (MM/DD/CCYY) Item 4: If there is insurance primary to Medicare, either through the patient’s or spouse’s employment or any other source, list the name of the insured here. When the insured and the patient are the same, enter the word SAME. If Medicare is primary, leave blank. Item 5: Enter the patient’s mailing address and telephone number. On the first line enter the street address; the second line, the city and state; the third line, the ZIP code and phone number. Item 6: Check the appropriate box for patient’s relationship to insured when item 4 is completed. Item 7: Enter the insured’s address and telephone number. When the address is the same as the patient’s use the word SAME. Complete this item only when items 4, 6, and 11 are completed. Item 8: Check the appropriate box for the patient’s marital status and whether employed or a Student. Item 9a: Policy or group number of secondary insurance. WRITE IT DOWN EXACTLY AS IT APPEARS ON THE INSURANCE CARD – Hyphens CAN be used! Item 9b: Date of Borth and Gender, Enter ONLY in the format MM/DD/YYYY, Male or Female Item: 9c: Secondary Insurance – Employer’s Name Item 9d: Secondary Insurance Company Name Item 10a-c: a: Employment (current or previous) Yes or No b: Auto Accident – Yes or No, State in which accident occurred (two letter identifier ONLY) c: other Accident – Yes or No Item 11a: Date of Birth and Gender, Enter ONLY in the format MM/DD/YYYY, Male or Female Item 11b: Subscriber’s Employer Item 11c: Subscriber’s (Primary) Insurance Co. Name Item 11d: “Is there another Health Benefit Plan? If the patient has other health benefits, medical or


dental, to which you will be submitting, the answer is YES. Item 12: Patient’s Signature, requires original signature unless a signed document with the patient’s/ subscriber’s authorization for release of information in the chart. If that is the case, “Signature on File” is permissible. Date must be stated as MM/DD/YY or MM/DD/YYYY. Item 13: Insured’s Signature, requires original signature of Subscriber/authorized person unless a signed document with the authorization for payment of benefits to the Provider’s Office is in the chart in that case, “Signature on File” is permissible Item 14: Date of Current Illness/Injury, State the date of the examination, whether it is an initial exam or a repeat visit, this requires the date when the diagnosis (-es) was/were made. Item 15: If Patient had same/similar illness, give first date of diagnosis Item 16: Dates Patient unable to work in current condition, Rarely applies in oral treatment situations, unless related to a traumatic injury, or after surgery. Item 17: Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician. Item 17a: Effective May 23, 2008. 17a is not to be reported but 17b MUST be reported when a service was ordered or referred by a physician. Item 17b: Enter the NPI of the referring/ordering physician listed in item 17. Item 18: Hospitalization Dates, Only for patients that were treated in a hospital. Enter admission

and discharge dates Item 19: Reserved for Local Use, Indicate any attachments being sent with claim i.e., operative

report, narrative. Item 20: Use of outside lab and Related Charges, when using a lab for appliances, prosthetics, or for ANY testing procedure. If the lab is billing the office – a charge is indicated here. Enter

the amount in the field to the LEFT of the vertical line. Use 00 for the cents if the amount is a whole number. Leave the right-hand field BLANK next to the “$ Charges” column. Do not use commas, decimal points, or dollar signs. i.e., $95.00 should be stated as 9500 to the LEFT of the vertical line.

Item 21: Correct Diagnosis Coding, Numerical codes FIRST, V codes next (describing patient history

factors affecting tx), E codes Last (side effects of medications, descriptors or how an accident occurred), Prioritization of diagnoses is VERY IMPORTANT – max. four codes allowed, ICD-9 codes should be prioritized from the most important problem being treated to the least significant one affecting the patient’s condition. Medicare claims will only accept one ICD-9 diagnosis code.

Item 22: Leave blank. Item 23: Prior Authorization Number, Number is given when a phone pre-authorization is called in. Item 24a: Dates of Service, In chronological order.


Item 24b: Place of Service, 11 – Office Item 24c: Emergency Treatment. If procedure is done on an EMERGENCY basis, indicate “Y” for YES

here Item 24d: Enter the appropriate CPT or HCPCS code. You can submit up to four modifiers, if needed.

If you are submitting a 41899, which is an unspecified code a narrative is required, either in box 19 or as a separate attachment.

Item 24e: Enter the diagnosis code reference number from Item 21. If more than one diagnosis code

relates to that line item submit as 1 2 3 4. Item 24f: Enter the charge for each listed service. Item 24g: Enter the number of days or units. If you are treating two teeth, submit 2 in this field.

Example: CPT code 41870, periodontal mucosal grafting, treated teeth 3, 4, 5. The number 3 would go in this field.

Item 24h: Leave blank. Not required. Item 24i: Leave blank. No longer required. Item 24j: Enter the rendering provider’s NPI in the shaded portion. NOTE: It is no longer necessary

for an individual provider (providers that have 1 NPI only) to enter his/her individual NPI in Item 24J as the rendering provider. Item 24J should be left blank.

Item 25: Enter the provider of service or supplier Federal Tax I.D. (Employer Tax Identification

number or Social Security Number) and check the appropriate box. DO NOT USE HYPHENS.

Item 26: Patient Account Number, enter the patient’s account number assigned by the provider.

This field is optional if the provider does not assign patient account numbers. Item 27: Accept assignment, check the appropriate block to indicate whether the provider of service

accepts assignment of Medicare benefits. Leave unchecked if you do not. Item 28: Enter total charges for the services (total of all charges in item 24f). Item 29: We recommend this be left blank, as it is oftem misunderstood and can cause incorrect

payments. Item 30: Leave blank. Item 31: Enter the signature of the provider, and the date signed. Item 32: Enter the name, address and zip code of the service location. Item 32a: If required by Medicare claims processing policy, enter the National Provider Identifier (NPI)

of the service facility.


Item 32b: Effective May 23, 2008, Item 32b is not to be reported. Item 33: Enter the provider of service billing name, address, zip code, and telephone number. Item 33a: Enter the NPI of the billing provider or group Item 33b: As of May 23, 2008 this field should not be reported.


Section 6 Problem Resolution Common Problems A. Lack of complete understanding between the patient and the periodontal office about the role of

dental insurance. 1. The periodontal office should assist the patient in understanding:

a. Dental insurance is a contract between a third party and the employer to assist the insured patient to meet his/her financial obligations to the dentist. It is not intended to relieve the patient of all financial responsibility.

b. It is the patient’s obligation to pay the periodontist for treatment rendered. The periodontist may assist the patient in completing claim forms, and may accept assignment of benefits, but should not be expected to accept undue delays in payment. If the periodontist has a contractual relationship with the third party payer, he/she can collect only the coinsurance amount from the patient and must accept the carrier’s negotiated fee as payment in full.

c. Medical and dental benefit plans differ markedly, particularly with regard to deductibles, coinsurance, yearly maximums, and scope of coverage. Virtually all dental policies have greater limitations on procedures covered, as well as on benefits provided for those covered services. Benefits vary from group to group even if the same carrier or employer is involved. Contracts are based on premiums paid by the employer and may vary because of union/non-union or management/labor status.

2. Most third parties will provide predetermination of benefits before periodontal treatment is initiated. A few plans even require it in order for benefits to be allowed. The carrier will inform the patient and the periodontist of the extent of benefits for the proposed treatment, but will not guarantee payment of those benefits. There may be changes in employment status, contract terms, or payment for other dental services between the time the predetermination is issued and the actual claim is adjudicated.

3. The patient and the periodontist must understand that most dental benefit contracts provide

benefits for certain procedures (such as periodontal maintenance) only at a given frequency. If those services are provided more frequently than the stated limitation, they are the financial responsibility of the patient.

4. Payment may be denied for certain procedures even though the patient and the periodontist agree

that the proposed treatment plan is in the patient’s best interest. The procedure may not be covered in the benefits contract or the clinical condition may not meet the carrier’s guidelines for coverage. Even though a procedure is listed as being covered, it may be subject to consultant review prior to approval of benefits. Predetermination of benefits is suggested for extensive treatment plan or if there is any question concerning coverage. If the proposed treatment is provided, the patient must understand that he/she is financially responsible for the entire fee.

B. Lack of proper communication and complete understanding between the periodontal office and the

third party payer. 1. Use the current version of the ADA Dental Claim Form. If a computer generated attachment or

superbill is used, it should be attached to a signed Dental Claim Form and returned to the carrier for predetermination or payment.

2. Type or print legibly all claim forms using appropriate ADA code numbers for all procedures. Do

not attempt to modify or adjust a code number to fit a new or different procedure. If a procedure


is not listed in the Code, use an unspecified code related to that procedure (example D4999) (unspecified periodontal procedure, by report) and include a narrative to describe the procedure.

3. When requesting payment, list the dates of service for each procedure. The date column should be

left blank on predetermination requests. 4. Indicate the teeth and/or areas of the oral cavity involved in treatment. This helps the carrier

understand variations in fees for similar procedures and diagnoses. If a fee submitted is higher or lower than the practitioner usually charges for the procedure, the reasons for this variation should be noted in Section 35.

5. When submitting a claim for payment, use the predetermination form with dates of service

returned by the carrier or note that benefits already have been predetermined. Failure to do so may result in the carrier considering the claim as a new submission and requesting diagnostic information already provided, thereby delaying payment of the claim.

6. When multiple procedures are performed in the same area or several procedures are carried out at

the same time, a rationale should be provided in Section 35 or on the body of the claim form along with a request for individual consideration.

C. Lack of an office insurance policy.

1. Keep a copy of all submitted claims. This saves time if the carrier loses a claim or if there is an inquiry regarding a specific claim.

2. Develop a system for filing and tracking claims. Timely inquiries should be made concerning processing delays.

3. Have a copy of the submitted form on hand when contacting the carrier regarding a question or problem with a specific claim.

4. Record the date, name of the person with whom you spoke, and the nature of your conversation when using the telephone to resolve problems with third party payers.

D. Lack of understanding of proper channels for resolving problems.

1. It may be helpful to establish rapport with someone of authority in the local or regional offices of those carriers most frequently involved with dental plans in your area.

2. When appealing a claim denial, return the form to the carrier along with reasons for the appeal,

pertinent diagnostic information, and a request that the dental consultant contact the periodontist to discuss the denial.

3. Many plans (particularly multi-state and self-funded ones) are governed by Employee Retirement

Income Security (ERISA) regulations which preempt most state insurance laws. Among other things, these regulations state that:

• a patient has the right to authorize a representative, including his/her dentist, to act on his/her

behalf in pursuing a benefit claim or appeal • a patient is entitled to notification of the specific reasons for an adverse benefit determination • a patient is entitled to receive a copy of any internal rule, guideline, protocol, or other criteria

relied upon in making an adverse decision • the decision-maker on appealed claims must be different from the person deciding the initial

claim


• appropriate health care professionals must be consulted when deciding appealed claims involving dental judgment

• the name of the dental professionals consulted must be disclosed as part of the claims process

4. Problems that cannot be resolved through the practitioner’s efforts should be communicated to the AAP Central Office via the Complaint Resolution Form (http://www.perio.org/members/tpi/Resoform.pdf) . The Academy offers the Complaint Resolution process as a member service. This service assists members who are having a problem with a claim for either reimbursement, EOB language, or any other issue or question.

The Academy’s Insurance Consultant, has played a key role in communicating with benefit carriers to help resolve problems that AAP members have with specific claims. He also has played an active role in resolving and interpreting policies and clinical procedures. Members needing assistance in resolving a problematic claim are asked to submit a Complaint Resolution Form (see link above) to the Clinical Affairs Manager. It is a fillable form on the website in the Members Only section. The form is completed by the office and signed by the patient (HIPAA Regulation), thereby allowing personal information to be released to the Academy. Other documentation needed is a copy of the claim, charting, copies of EOB’s or predeterminations, and any other correspondence to or from the benefit carrier. After completion of filling out the form it can be faxed to the Clinical Affairs Manager at 312/573-3234. Staff will determine if the issue can be handled internally, or if it needs to be forwarded to the AAP Insurance Consultant. He will then review the documentation to determine the appropriate course of action. Then he will discuss the situation with the member and, if necessary, contact the benefit carrier on the member’s behalf in an attempt to resolve the problem. After contact with the carrier, he will then notify the member to discuss resolution of the issue and any additional action needed on the member’s part. 5. If a dispute cannot be resolved despite intervention by the Academy, ask for a Peer Review Committee hearing at your local dental society. Problem Solving Flow Chart (http://www.perio.org/members/tpi/Probfc.pdf) Complaint Resolution Form (http://www.perio.org/members/tpi/Resoform.pdf)


Section 7 AAP Insurance Policy Statements

These Policy Statements are intended to help you adjudicate claims with third party carriers and can be viewed at the Academy’s Web site: http://www.perio.org/members/tpi/policy/policyindex.html Section 8 NDEDIC Glossary of Dental Benefit Plans and Related Terminology For a glossary of dental benefit plan terms, visit: http://perio.org/members/tpi/cpt/NDEDIC-Glossary.pdf


Section 9 AAP Frequently Asked Questions The Academy has a collection of Frequently Asked Questions (http://www.perio.org/members/tpi/tpi-faq.htm) for use by Members. Members with third-party questions not answered in this section are encouraged to contact Pam Throw, Clinical Affairs Manager at: Phone: 800/282-4867 ext. 3241 E-mail: [email protected]


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