Coding Guide for Dental Services - Optum360Coding.com Guide Den… · method of translating medical terminology into codes. Codes within the system are either numeric or alphanumeric

Coding Guide forDental Services

A comprehensive coding, billing, and reimbursementresource for dental services

IntroductionCoding systems and claim forms are therealities for modern health care. Of themultiple systems and forms available, what youuse is greatly determined by the setting, thetype of insurance, and your practice style.

The Coding Guide for Dental Services provides acomprehensive look at the coding andreimbursement systems used by dentists. It isorganized topically and numerically, and can beused as a comprehensive coding andreimbursement resource and as a quick-lookupresource for coding.

Coding SystemsThe coding systems discussed in this codingguide seek to answer two questions: What waswrong with the patient (i.e., the diagnosis ordiagnoses) and what was done to treat thepatient (i.e., the procedures or servicesrendered).

Coding systems grew out of the need for datacollection. By having a standard notation forthe procedures performed and for the diseases,injuries, and illnesses diagnosed, it would bepossible to identify those treatments that weremost effective and to determine practicepatterns. It was not long before these earlycoding systems were also being used as thebasis for paying claims.

HCPCS Level I (CPT) CodesPhysicians’ Current Procedural Terminology,Fourth Edition (CPT) and the HealthcareCommon Procedure Coding System (HCPCS)codes are used to indicate what services orsupplies were rendered and which procedureswere performed during the patient’s visit. Toreceive timely and appropriate reimbursement,one must submit a properly coded claim.

The Centers for Medicare and Medicaid Services(CMS), in conjunction with the AmericanMedical Association (AMA), the AmericanDental Association (ADA), and several otherprofessional groups, has developed, adopted,and implemented a three-level coding systemdescribing services tendered to patient. Level I isthe CPT Coding System.

The most commonly used coding system forreporting outpatient services is CPT, which ispublished annually and copyrighted by theAMA. CPT codes predominantly describemedical services and procedures and have beenadapted to provide a common billing languagethat providers and payers can use for paymentpurposes. CPT codes are primarily used by thedental provider when indicating services suchas gingivectomy or gingivoplasty. They arerequired for billing by both private and publicinsurance carriers, managed care companies,and workers’ compensation programs.

The AMA’s CPT Editorial Panel reviews thecoding system and makes periodic changes tocodes and their descriptions. These changes areposted on the AMA’s Web site with the datethese code changes are effective. Most codechanges by the AMA occur annually and areeffective January 1 of each year. The panelaccepts information and feedback by providersabout new codes and revisions to existingcodes that could better reflect the service orprocedure being provided.

HCPCS Level II CodesHCPCS Level II codes are commonly referredto as national codes or by the acronym HCPCS(Healthcare Common Procedure CodingSystem—pronounced “hik piks”). HCPCScodes are used for billing Medicare andMedicaid patients and have also been adoptedby some third-party payers.

HCPCS Level II codes, periodically updatedand published annually by CMS, are intendedto supplement the CPT coding system byincluding codes for non-physician services,durable medical equipment (DME), and officesupplies. These Level II codes consist of onealphabetic character (A through V) followed byfour numbers. Dental providers commonly usethe “D” code section of the HCPCS Level IIsystem.

Non-Medicare acceptance of HCPCS Level IIcodes is inconsistent. Providers should checkwith the payer before billing these codes.

CPT is a registered trademark of the American Medical Association.©2003 Ingenix, Inc. 1

HCPCS Level III (Local) CodesAll HCPCS local codes have been phased out, aprocess that began in 2002. As the first step,effective October 16, 2002, carriers wererequired to eliminate all local codes andmodifiers that had not been approved by CMS.Carriers had to identify those codes andmodifiers in use, crosswalk them to nationalcodes, and delete any that were not approved.If carriers felt that an unapproved code shouldbe retained for use, they had to submit arequest for a temporary national code for thatservice/supply, with an explanation as to whythe code should be retained. These requestswere due to the regional offices by April 1,2002.

The next phase was the elimination of theofficial HCPCS Level III local codes andmodifiers by December 31, 2003. Again,carriers were required to review all local codesin their systems, crosswalk them to appropriatenational codes, and submit requests forreplacement temporary national codes by April1, 2003. Temporary national codes that arerequested and approved will be implementedJanuary 1, 2004.

Local codes had been used to denote newprocedures or specific supplies for which therewas no national code. For Medicare, these five-digit alphanumeric codes used the letters Wthrough Z. Each carrier created local codes asthe need dictated. However, carriers wererequired to obtain approval from CMS's centraloffice before implementing them. The Medicarecarrier was responsible for providing you withthese codes.

As a result of the Consolidated AppropriationsAct of 2001, and as part of the National CodeData Sets implemented under the HealthInsurance Portability Accountability Act, theSecretary of Health and Human Services wasinstructed to maintain and continue the use ofHCPCS level III codes through December 31,2003.

Program Memorandum (PM) AB-01-45instructed carriers to take the following stepsto implement the law on April 29, 2001:

• Maintain and accept current level IIIHCPCS codes and modifiers untilDecember 31, 2003. However, carrierswere not allowed to create any newHCPCS Level III codes or modifiers.

• Carriers were to reinstate any HCPCSLevel III codes and modifiers they mayhave eliminated after August 16, 2000.

• Carriers were to publish on their Web sitesany HCPCS Level III codes and modifierswith their descriptors that were in effectAugust 16, 2000.

Medicare carriers who wished to establish atemporary national code were required tosubmit the request to their regional office. Theregional office then submitted thatrecommendation to the central office forapproval.

ICD-9-CM Classification System

The International Classification of Diseases,Ninth Revision, Clinical Modification(ICD-9-CM) is used to classify illnesses,injuries, and patient encounters with dentaland health care practitioners.

The ICD-9-CM classification system is amethod of translating medical terminology intocodes. Codes within the system are eithernumeric or alphanumeric and are composed ofthree, four, or five characters. A decimal pointfollows all three-character codes when fourthand fifth characters are needed. Codinginvolves using a numeric or alphanumeric codeto describe a disease or injury. For example,dental caries limited to enamel is coded to521.01.

Generally, the reason the patient soughttreatment should be sequenced first whenmultiple diagnoses are listed. Many claimforms, with the exception of the ADA dentalform, require that the appropriate ICD-9-CMcode be reported rather than a description ofthe functional deficit or defect.

Dental providers need to be aware of thenecessity for specific diagnosis coding. Usingonly the first three digits of the ICD-9-CM

2 ©2003 Ingenix, Inc.

Coding Guide for Dental Services

Documentation — AnOverviewThe role played by dental documentation hasalways been a supportive one. As the practiceof dentistry became more sophisticated andcomplex, the need to record specific clinicaldata grew in importance. What certainly beganas a simple written mechanism to jog thememory of a treating dentist evolved into amore refined system to service others assistingin patient care. Tracking patient historyemerged as a fundamental element in planninga course of treatment. When dental specialtiesevolved, the patient record offered a means toprovide pertinent data for treatment, referrals,and consultations.

Still, no clear standards exist for recordingdental patient information. Dentaldocumentation was seen, maintained, and usedalmost exclusively by the dentist and theirstaff. Patient care information was neversubmitted to insurance companies or togovernment payers; only rarely did dentaldocumentation become the focus ofmalpractice suits.

Prior methods of dental documentation werenot adequate to demonstrate provision of allcare and/or dental necessity. Some of thosemethods included the preprinted card whereall care was noted in a single line entry andindicated on an illustration of the mouth andteeth. Other dentists used copies of the ADAor other billing forms as their documentationof services.

A national increase in dental malpracticeclaims and awards abruptly altered the strictlyclinical nature of documentation. The patientdental record was swept into the broad realmof civil law. Since most dental liability suitsapproach resolution years after the contestedcare, the dental record provides a main sourceof information about what happened and why.The patient record became a legal document, abasis to reconstruct the quality and quantity ofdental care services. In many instances, it alsoserves as a dentist’s only defense againstcharges of malpractice.

Marked change in the Medicare program alsoserved to broaden the influence of medicaldocumentation. For example, the Centers ofMedicare and Medicaid Services (CMS),Medicare’s federal administrator, authorizes theprogram’s regional carriers to review paidclaims to determine whether the care wasmedically necessary, as mandated under theSocial Security Act of 1996.

This type of review checks processed and paidclaims against the documentation recorded atthe time of service. The aim is to ensure thatMedicare dollars are administered correctlyand dental documentation must support thedental necessity of the service, to what extentthe service was rendered, and why it wasmedically justified. For example, based onfindings from a routine x-ray exam, a dentistmay believe further studies or treatment arewarranted. Documentation must indicate thenecessity for the added studies. However, theservice may require prior authorization fromthe payer, depending on payer guidelines.

Medicare does not pay for services that are“medically unnecessary,” according toMedicare standards. Patients are not liable topay for such services if the service isperformed without prior notification from thephysician. Medical necessity requires items andservices to be:

• Consistent with symptoms or diagnosis ofdisease or injury

• Necessary and consistent with generallyaccepted professional dental standards(e.g., not experimental or investigational)

• Furnished at the most appropriate levelthat can be provided safely and effectivelyto the patient

A significant number of providers were foundto have billed for services that were notprovided or found to be medically unnecessary.These findings led to the creation of the federalfraud and abuse program coordinated byseveral federal organizations, including theDepartment of Health and Human Services

©2003 Ingenix, Inc. 5

(HHS) and its agencies, CMS, and the Office ofInspector General (OIG).

Commercial insurance companies were quickto follow suit. Similar to CMS, private payersmonitor claims to uncover coding mistakesand to verify that the documentation supportsthe claims submitted. Although there are nonational guidelines for proper documentation,the guidelines this chapter provides shouldensure better quality of care and increase thechances of full and fair reimbursement.

Methods of DocumentationThe problem-oriented medical record (POMR)is one documentation method. The provideridentifies problems individually and arrangesthem for resolution. The POMR has fourelements: (1) database, (2) problem list, (3)initial plans, and (4) progress notes.

At minimum, the data portion of the POMRincludes information such as chief complaint,present illness, past, present, family, and socialhistory, review of systems, physicalexamination, and baseline ancillary data.Medical history may play an important part ofdental care as many diseases have dentalmanifestations or dental treatment may impactthe medical care of the patient with diseaseprocesses such as heart disease, coagulationdefects, and organ replacement.

The problem list consists of any problem thatrequires management or diagnostic workup. Itmay be a symptom, an abnormal finding, aphysiological finding, or a specific diagnosis.The provider adds or changes the list asproblems are identified and resolved.

The third portion, initial plans, states what theprovider plans to do to learn more about theproblem, to treat it, and to educate the patientabout the problem and treatment.

Progress notes are the final element of thePOMR. Each problem is documented withregard to the following: (S)ubjective findings(symptoms); (O)bjective findings (measurable,observable); (A)ssessment (interpretation orimpression of the current condition); and(P)lan (treatment). This process is often

referred to by the acronym “SOAP.” Althoughoriginally instituted for the medical record, thismethod is easily adaptable to dental care andprovides a consistent format across all healthcare specialties.

The integrated dental record is another methodof documentation that is strictly chronologicalwithout section divisions by the source of care.This keeps the episode of care documented inone continuous flow by date; but may make itmore difficult to compare information from thesame source, such as radiology reports orconsultations. Because of this disadvantage,some chart order arrangements may integratecertain types of forms while maintainingothers, such as radiology reports, togetherchronologically.

No specific format for documentation isrecommended. It depends on the provider. Butit is important that anyone reading the dentalrecord be able to understand from thedocumentation the service rendered and thereason for the service.

General Guidelines forDocumentationDocumentation is the recording of pertinentfacts and observations about a patient’s healthhistory, including past and present illnesses,tests, treatments, and outcomes. The dentalrecord documents the care of the patient to:

• Enable a dentist or other health careprofessionals to plan and evaluate thepatient’s treatment

• Enhance communication and promotecontinuity of care among dentists andother health care professionals involved inthe patient’s care

• Facilitate claims review and payment

• Assist in utilization review and quality ofcare evaluations

• Reduce hassles related to dental review

• Provide clinical data for research andeducation



Reimbursement and FeeCalculationsReceiving appropriate reimbursement fordental and health care services can sometimesbe difficult because of the rules and paperworkinvolved. The following reimbursementguidelines are offered to help you understandthe various requirements for getting claimspaid promptly and correctly.

Coverage IssuesFirst, you need to know what services arecovered. Covered services are services payableby the insurer in accordance with the terms ofthe benefit-plan contract. Such services mustbe documented and medically necessary forpayment to be made. Typically, payers definemedically necessary services or supplies as:

• Services that have been established as safeand effective

• Services that are consistent with thesymptoms or diagnosis

• Services that are necessary and consistentwith generally accepted dental or medicalstandards

• Services that are furnished at the mostappropriate, safe, and effective level

The Medicare program does not cover mostroutine dental services. The Medicare lawclearly excludes coverage “for services inconnection with the care, treatment, filling,removal, or replacement of teeth or structuresdirectly supporting teeth” and dentists may notbe required to submit Medicare claims for suchservices.

A narrow exception permits coverage of a fewdental services that are necessary to theprovision of certain Medicare covered medicalservices. For example, Medicare may cover thefollowing services:

• Extraction of a tooth as part of a repair ofa fractured jaw

• Maxillofacial surgery for pathological ortraumatic medical conditions (e.g., in caseof a serious injury)

• Prosthetic rehabilitation to replace or treatcertain oral and/or facial structures relatedto covered medical and surgicalinterventions (e.g., cancer surgery)

• Extraction of teeth prior to radiationtreatment of the jaw

• Oral examination prior to kidneytransplantation

Medicare may also cover certain medicalprocedures that dentists are licensed toperform (e.g., a biopsy for oral cancer).

Other payer policies vary regarding thecoverage of dental services and, therefore, thepayer should be contacted before service isrendered.

Payment MethodologiesOnce covered services are known, the nextissue to resolve is how you will be paid forthose services. Over the last several years,there have been major changes to providerpayment systems. The following will discussthe many varieties of payment methodologiesused by Medicare and other third-party payersfor dental claims.

Usual, Customary, and ReasonableFee-for-service reimbursement based onreasonable and customary charges has been thetypical payment method for reimbursingproviders used for most of Medicare’s history,as well as by private payers. Medicare’sprevious “customary, prevailing, andreasonable” (CPR) payment methodology wassimilar to the private sector payers’ chargesystem of “usual, customary, and reasonable(UCR).”

This payment system is designed to payproviders based on their actual fees. Theprovider is paid the lowest charge occurringamong the actual fee for the service, theprovider’s customary charge (figured as themedian of that individual’s charges for theservice over a defined time period), or theprevailing usual charge of all providers withinthe area. There was no attempt to reimburse


services based on the work required. Owing tothe diversity in fees charged for the sameservices, this system allows for a wide variancein payment for the same service. Withexploding health care costs in the 1970s and1980s, serious cost-containment needs formedical and dental services led to evaluatingalternative reimbursement methodologies.

Fee SchedulesFee schedules are replacing the customary andreasonable payment methodology as thesystem of choice. Fee schedules eliminate thewide payment variation for similar servicesthat occurs with the customary and reasonablemethod and allows both payers and providersto estimate the amount of reimbursement theycan expect to pay and receive. Using a feeschedule to maintain a fee-for-service systemwas considered by many medical professionalsto be critical in protecting physicians’ clinicaland professional autonomy. A key factor indeveloping a fee schedule can be the use of arelative value scale.

Relative Value Scale (RVS)A relative value scale (RVS) ranks servicesaccording to “value” where that value isdefined with respect to a base value. Allservices are assigned a unit value, with morecomplex, more time-consuming serviceshaving higher unit values and vice versa.Values are then multiplied by a dollarconversion factor to become a fee schedule.

Resource-Based Relative Value Scale(RBRVS)After much debate and analysis, Medicaredecided to enhance the RVS payment schedulebased on the costs of the resources required toprovide the services. In a resource-based RVS,the services are ranked based on the relativecosts of the resources required to provide thoseservices as opposed to the average fee for theservice, or average prevailing Medicare charge.The Medicare RBRVS that was implemented inJanuary 1992 and fully phased in by January1996 was developed using the results of aHarvard University studies team that firstidentified and defined three distinct

components affecting the value of each serviceor procedure:

• Physician work component reflecting thephysician’s time and skill

• Practice expense (PE) componentreflecting the physician’s rent, staff,supplies, equipment, and other overhead

• Malpractice (malprac) insurancecomponent reflecting the relative risk orliability associated with the service

Relative value units (RVUs) are assigned toeach component and the sum of thesecomposes the total value of each service. CMSassigns a dollar amount to each CPT orHCPCS code by applying a dollar conversionfactor to the total value for each service;however, geographic practice cost indices(GPCIs) must first be applied to eachcomponent prior to the dollar amountconversions that become the reimbursementrates found in the fee schedule. The GPCIs arefigured into the three component values andadded for a total geographically adjusted valuefor the service, which is then multiplied by theconversion factor to yield the locality-specificMedicare fee in the payment schedule.

Although the RBRVS was developedspecifically for reimbursement of Medicarecovered services, more than 70 percent of non-Medicare payers use RBRVS to establish theirfees and maximum allowable reimbursementrates.

Conversion factors are national dollar amountsthat are used to convert relative values intopayment amounts. The Medicare conversionfactor is published yearly in the FederalRegister during the late fall with the Medicarephysician fee schedule final rule.

RVUs are not assigned for the following typesof services:

• Services that require carrier pricing orpayment “by report” such as unlisted codes

• Services reported with local codes



The Insurance ProcessThe most important document for correctreimbursement is the insurance claim form.Other information, such as operative reports,chart notes, and cover letters, may establishmedical necessity, but the claim “sets thestage.”

With commercial insurance companies, submitthe claim directly to the payer or provide thepatient with the necessary information tosubmit the claim. If there is a signed agreementwith an HMO or PPO, the office may berequired to send the claim directly to theinsurer. Medicare requires that the officesubmit all Medicare claims directly to thecarrier, whether participating or not in theMedicare program.

For paper claims, use the appropriate form.Multiple forms are available for dental claims,including the accepted national dental form(revised January 1, 2003 to be HIPAAcompliant) mandated by many state Medicaidpayers or payer specific forms created byindividual dental payers. For medical servicesbilled to Medicare or other medical healthpayers, use the standard CMS-1500 claim formfor professional services. When submittingcharges, be sure to complete the formscompletely and accurately.

The term “claims processing” describes thecourse of submitting a claim to the payer andsubsequent adjudication. Understanding howthis process works allows providers and staffmembers to file claims properly and leads tomaximum and timely reimbursement. Inaddition, this knowledge will allow theprovider’s office to serve as a resource topatients in understanding the process.

What to Include on ClaimsPatient InformationBefore filing any claim, obtain clear, accurateinformation from the patient, and update theinformation regularly. Most offices verify theinformation at each visit. A uniform policy formultiple provider offices or clinics makeseveryone accountable for current and correctpatient data.

Primary vs. Secondary CoverageHouseholds with dual incomes often havemore than one insurer. Determine which is theprimary and which is the secondary insurancecompany. For commercial plans, thesubscriber’s or insured’s insurance company isalways primary for the subscriber. In otherwords, the husband’s insurance company isprimary for him and the wife’s insurancecompany is primary for her. However, theprimary insurance company for anydependents is determined by the insureds’birthdays, the primary insured being theindividual whose birthday is first during theyear. This is often referred to as the “birthdayrule.” For example, if the husband’s birthday isOctober 14, 1960 and the wife’s birthday isMarch 1, 1962, the wife is primary for theirdependents because her birthday is first duringthe year (year of birth is ignored).

Assignment of Benefits and Release ofInformationConsider adding an assignment of benefitsstatement to the patient information form. Itshould state that the patient has agreed to haveinsurance payments sent directly to theprovider and that medical information can bereleased to the patient’s insurance company.Assignment reduces collection expenses. Thereare payers that require a current signature witheach claim. It is important to review yourassignment of benefit and release ofinformation statements to ensure that you areHIPAA compliant.

If the office participates with Medicare, anassignment of benefits and release of billing arenecessary and must be kept on file.

Determining CoverageA patient’s insurance coverage should beverified before any service is rendered with thecommon sense exception of emergencytreatment. This policy should not applyexclusively to new patients. Establishedpatients may have changed employers, marriedor divorced, or are no longer covered by thesame policy that was in effect during the lastvisit. The law requires Medicaid patients to


provide current proof of eligibility with eachvisit.

PreauthorizationDetermining in advance the benefits andallowables provides the dentist’s office withreimbursement figures before the patient’s visit.Under most circumstances, the office should beable to discuss the deductible, copayment, andbalance over and above the allowable with thepatient prior to providing costly surgicalservices. Asking a few pointed questions of thepatient and insurer will provide additionalinformation regarding deductibles, forexample:

• How much is the deductible and has itbeen met for the current year?

• What are the allowables for the quotedprocedures?

• What percentage of the allowables will bepaid?

Clean ClaimsClaims submitted with all of the informationnecessary for processing are referred to as“clean” and are usually paid in a timelymanner. Paying careful attention to whatshould appear on the claim form helps producethese clean claims. Common errors include thefollowing:

• Failure to pay attention tocommunications from carriers (includingMedicare and Medicaid transmittals)

• An incorrect patient identification number

• Patients’ names and addresses that differfrom the insurers’ records

• Provider tax identification number,provider number, or Social Securitynumber that is incorrect or missing

• No or insufficient information regardingprimary or secondary coverage

• Missing authorized signatures — patientand/or provider

• Dates of service that are incorrect or don’tcoincide to the claims information sent byother providers

• Dates that lack the correct number ofdigits

• A fee column that is blank or not itemizedand totaled

• Incomplete patient information

• Invalid CPT, HCPCS, ADA, or ICD-9-CMcodes, or diagnostic codes that are notlinked to the correct services or procedures

• An illegible claim

The Health Insurance Portabilityand Accountability Act (HIPAA)The Health Insurance Portability andAccountability Act of 1996 (Public Law104–191) is a complex, multi-faceted lawcontaining a number of provisions andamendments. It was passed as a means ofimproving the portability and availability ofhealth insurance coverage for individuals andgroups. While insurance reform (Title 1) is animportant aspect of the law, it is the anti-fraudand abuse provisions that have the greatestimpact on provider practices and dailyoperational activities. Other provisionspromote the use of medical savings accounts,improving access to long-term care servicesand coverage, and simplification of healthinsurance administration.

Possibly the best approach is to be certain thatyour practice keeps abreast of the rapidchanges taking place as the different provisionsof HIPAA are implemented. HIPAA also affectsservices by dentists, medical suppliers, and theprovision of drugs. CMS relies on the DentalContent Committee of the American DentalAssociation (ADA) for all dental health careservice consultant advice. One of the bestsources of information is the CMS Web site,which provides not only backgroundinformation, but also keeps you up to datewith current rules and CMS requirements. Thataddress is http://www.cms.hhs.gov/hipaa

Administrative Simplification ProvisionsThe Administrative Simplification provisions ofHIPAA (Title II) requires the Department ofHealth and Human Services (HHS) to establishnational standards for electronic health care



CDT-4 only © 2002 American Dental Association. All Rights Reserved.©2003 Ingenix, Inc. 53

HCPCS Level II Definitionsand GuidelinesOne of the keys to gaining accuratereimbursement lies in understanding themultiple coding systems that are used toidentify services. To be well versed inreimbursement practices, coders should befamiliar with the HCPCS Level II ICD-9-CM,CPT, and CDT-4 coding systems. The first ofthese, the HCPCS Level II system, isincreasingly important to reimbursement, as ithas been extended to a wider array of medicalservices.

HCPCS Level II codes commonly are referredto as national codes or by the acronymHCPCS, which stands for the HealthcareCommon Procedure Coding System(pronounced “hik-piks”). When using HCPCSLevel II codes, keep the following in mind:

• CMS does not use consistent terminologyfor unlisted services or procedures. Thecode descriptions may include any one ofthe following terms: unlisted, nototherwise classified (NOC), unspecified,unclassified, other, and miscellaneous.

• When billing for specific supplies andmaterials, avoid CPT code 99070 (generalsupplies) and be as specific as possibleunless the local carrier directs otherwise.

• Coding and billing should be based on theservice and supplies provided.Documentation should describe thepatient’s problems and the serviceprovided to enable the payer to determinereasonableness and necessity of care.

• Refer to Medicare coverage reference todetermine whether the care provided is acovered service.

SymbolsSymbols used in the HCPCS Level II systemmay be presented in various ways, dependingon the vendor. In this publication, the patternestablished by the AMA and ADA in the CPTand CDT-4 code books is followed. Forexample, bullets and triangles signify new andrevised codes, respectively.

When a code is new to the HCPCS Level IIsystem, a bullet (●) appears to the left of thecode. This symbol is consistent with the CPTsystem's symbol for new codes. The bulletrepresents a code never before seen in theHCPCS coding system.

A triangle (▲) is used (as in the CPT system)to indicate that a change in the narrative of acode has been made from the previous year'sedition. The change made may be slight orsignificant, but it usually changes theapplication of the code.

HCPCS Level II CodesThe following is a list of the HCPCS Level IIdental and other HCPCS Level II supply codesused to identify supplies commonly used bydentists.

Medical and Surgical SuppliesA4000–A8999This section covers a wide variety of medicaland surgical supplies, and some durablemedical equipment (DME), supplies andaccessories.

A4550 Surgical trays

MCM 15030

A4649 Surgical supply;miscellaneous

Dental Procedures D0000-D9999Items and services, in connection with thecare, treatment, filling, removal, orreplacement of teeth, or structures directlysupporting the teeth, are not covered byMedicare. Prosthetic devices that replace thefunction of a permanently inoperative ormalfunctioning internal body organ are,however, a covered service under theProsthetic Devices guidelines.

The hospitalization or nonhospitalization of apatient has no direct bearing on the coverageor exclusion of a given dental procedure.

This section incorporates numeric codes anddescriptors from CDT-4, which is copyrightAmerican Dental Association.

Prosthodontics (Removable) D5000-D5899

D5120 Complete denture—mandibular

D5130 Immediate denture—maxillary

D5140 Immediate denture—mandibular

D5510 Repair broken completedenture base

D5620 Repair cast framework

D5630 Repair or replace broken clasp

D5640 Replace broken teeth—pertooth

D5650 Add tooth to existing partialdenture

D5660 Add clasp to existing partialdenture

D5670 Replace all teeth and acrylicon cast metal framework(maxillary)

D5671 Replace all teeth and acrylicon cast metal framework(mandibular)

Maxillofacial Prosthetics D5900-D5999

D5913 Nasal prosthesis

D5914 Auricular prosthesis

D5915 Orbital prosthesis

D5916 Ocular prosthesis

D5919 Facial prosthesis

D5922 Nasal septal prosthesis

D5923 Ocular prosthesis, interim

D5924 Cranial prosthesis

D5925 Facial augmentation implantprosthesis

D5926 Nasal prosthesis, replacement

D5927 Auricular prosthesis,replacement

D5928 Orbital prosthesis,replacement

D5931 Obturator prosthesis, surgical

D5932 Obturator prosthesis,definitive

D5933 Obturator prosthesis,modification

D5934 Mandibular resectionprosthesis with guide flange

D5935 Mandibular resectionprosthesis without guideflange

D5936 Obturator/prosthesis, interim

D5937 Trismus appliance (not forTMD treatment)

MCM 2130

D5951 Feeding aid

MCM 2336, MCM 2130

D5954 Palatal augmentationprosthesis

D5955 Palatal lift prosthesis,definitive

D5958 Palatal lift prosthesis, interim

D5959 Palatal lift prosthesis,modification

D5986 Fluoride gel carrier

D5987 Commissure splint

MCM 2136, MCM 2336

D5988 Surgical splint. See also CPT.

D5999 Unspecified maxillofacialprosthesis, by report

Implant Services D6000-D6199

D6053 Implant/abutment supportedremovable denture forcompletely edentulous arch

MCM 2136

CDT-4 only © 2002 American Dental Association. All Rights Reserved.54 ©2003 Ingenix, Inc.



HCPCS Level II D Codes

Work PE Mal-Value RVU prac Total

D0473 . . . . . . . . . . 0.00 1.58 0.00 1.58

D0473D0473 Accession of tissue, gross and

microscopic examination,preparation and transmission ofwritten report

ExplanationThis examination is a gross and microscopicpathology exam or a gross and microscopictissue exam. The tissue is harvested in thecourse of a surgery and sent for routine labevaluation. Tissue is submitted in acontainer labeled with the tissue source,preoperative or tentative diagnosis, andpatient identification information.Specimens from separate sites must besubmitted in separate containers, eachlabeled with the tissue source. It includesboth a gross and microscopic examinationwith the microscopic exam mainly toconfirm the identification or the absence ofdisease. This code includes preparation andtransmission of a written report, but not theremoval of the tissue sample itself from thepatient.

Coding TipsRemoval of tissue for examination isreported separately. For biopsy of hard oraltissues (tooth and bone), see D7285. Forbiopsy of soft oral tissues, see D7286.

Terms To KnowTissue. A group of similar cells that formdefinite structures or tissues. These aregrouped into organs. Organs, by definition,are composed of tissues of different kinds.Tissue types include epithelial tissue, whichline the outside of the body and the innersurface of internal organs; muscle tissue,which can be voluntary (found in limbs andplaces where movement is voluntary) orinvoluntary (found in the heart anddigestive system where movement is notunder conscious control); connective tissue,

such as fat, cartilage, bone, or blood; andnerve tissue.

HCPCS CodesThis service is usually provided at the samesession as another service. See the primaryservice for HCPCS Level II codes.

ICD•9 Diagnostic Codes143.0 Malignant neoplasm of upper gum143.1 Malignant neoplasm of lower gum143.8 Malignant neoplasm of other sites

of gum145.6 Malignant neoplasm of retromolar

area145.9 Malignant neoplasm of mouth,

unspecified site754.81 Pectus excavatum

Associated CPT Codes88305 Level IV – Surgical pathology, gross

and microscopic examination, non-traumatic gingiva/oral mucosa,nasopharynx/oropharynx, biopsynerve, biopsy odontogenic/dentalcyst omentum, TUR salivary gland,biopsy sinus, paranasal biopsy skin,other than cyst/tag/debridement,biopsy soft tissue, other than tumor

88307 Level V – Surgical pathology, grossand microscopic examination,odontogenic tumor, soft tissue mass(exept Lipoma) – biopsy/simpleexcision

MCM/CIM ReferencesCIM 50-26, MCM 2136, MCM 2336



Work PE Mal-Value RVU prac Total

D0474D0474 Accession of tissue, gross and

microscopic examination,including assessment of surgicalmargins for presence of disease,preparation and transmission ofwritten report

ExplanationThis examination is a gross and microscopicpathology exam or a gross and microscopictissue exam with the evaluation of surgicalmargins for the presence of disease. Thetissue is harvested in the course of a surgeryand sent for routine lab evaluation. Tissue issubmitted in a container labeled with thetissue source, preoperative or tentativediagnosis, and patient identificationinformation. Specimens from separate sitesmust be submitted in separate containers,each labeled with the tissue source. Itincludes both a gross and microscopicexamination and an additional level ofevaluation to determine whether themargins of the surgically excised tissuepresent with disease or have been removedclear of disease. This code includespreparation and transmission of a writtenreport, but not the removal of the tissuesample itself from the patient.

Coding TipsRemoval of tissue for examination isreported separately. For biopsy of hard oraltissues (tooth and bone), see D7285. Forbiopsy of soft oral tissues, see D7286.

Terms To KnowTissue. A group of similar cells that formdefinite structures or tissues. These aregrouped into organs. Organs, by definition,are composed of tissues of different kinds.Tissue types include epithelial tissue, whichline the outside of the body and the innersurface of internal organs; muscle tissue,which can be voluntary (found in limbs and

places where movement is voluntary) orinvoluntary (found in the heart anddigestive system where movement is notunder conscious control); connective tissue,such as fat, cartilage, bone, or blood; andnerve tissue.

HCPCS CodesThis service is usually provided at the samesession as another service. See the primaryservice for HCPCS Level II codes.

ICD•9 Diagnostic Codes143.0 Malignant neoplasm of upper gum143.1 Malignant neoplasm of lower gum143.8 Malignant neoplasm of other sites

of gum145.6 Malignant neoplasm of retromolar

area145.9 Malignant neoplasm of mouth,

unspecified site754.81 Pectus excavatum

Associated CPT Codes88305 Level IV – Surgical pathology, gross

and microscopic examination, non-traumatic gingiva/oral mucosa,nasopharynx/oropharynx, biopsynerve, biopsy odontogenic/dentalcyst omentum, TUR salivary gland,biopsy sinus, paranasal biopsy skin,other than cyst/tag/debridement,biopsy soft tissue, other than tumor

88307 Level V – Surgical pathology, grossand microscopic examination,odontogenic tumor, soft tissue mass(exept Lipoma) – biopsy/simpleexcision

MCM/CIM ReferencesCIM 50-26, MCM 2136, MCM 2336

D0474 . . . . . . . . . . 0.00 1.91 0.00 1.91

Impaction, impacted — continuedtooth, teeth 520.6

with abnormal position (same or adjacenttooth) 524.3

Impaired, impairment (function) mastication 524.9 2

Impingement, soft tissue between teeth 524.2Inanition 263.9 2

fever 780.6Incompetency, incompetence, incompetent

velopharyngeal (closure) acquired 528.9 2

Increase, increasedcold sense (see also Disturbance, sensation)

782.0heat sense (see also Disturbance, sensation)

782.0Infantile — see also condition

melanodontia 521.05Infection, infected, infective (opportunistic)

136.9 2

Aerobacter aerogenes NEC 041.85alveolus, alveolar (process) (pulpal origin) 522.4anaerobes (cocci) (gram-negative) (gram-positive)

(mixed) NEC 041.84Bacillus NEC 041.89

coliform NEC 041.85fragilis NEC 041.82Friedländer’s NEC 041.3

bacterial NEC 041.9 2

specified NEC 041.89anaerobic NEC 041.84gram-negative NEC 041.85

anaerobic NEC 041.84Bacteroides (fragilis) (melaninogenicus) (oralis)

NEC 041.84Clostridium (haemolyticum) (novyi) NEC 041.84

perfringens 041.83coccus NEC 041.89dental (pulpal origin) 522.4due to or resulting from

surgery 998.59Eaton’s agent NEC 041.81Enterobacter aerogenes NEC 041.85enterococcus NEC 041.04Escherichia coli NEC 041.4Eubacterium 041.84focal

teeth (pulpal origin) 522.4Fusobacterium 041.84Gardnerella vaginalis 041.89gingival (chronic) 523.1

acute 523.0gram-negative bacilli NEC 041.85

anaerobic 041.84gum (see also Infection, gingival) 523.1Helicobacter pylori (H. pylori) 041.86Hemophilus influenzae NEC 041.5HIV V08

with symptoms, symptomatic 042human immunodeficiency virus V08

with symptoms, symptomatic 042jaw (bone) (acute) (chronic) (lower) (subacute)

(upper) 526.4Klebsiella pneumoniae NEC 041.3maxilla, maxillary 526.4Mima polymorpha NEC 041.85mixed flora NEC 041.89

Infection, infected, infective — continuedmouth (focus) NEC 528.9 2

mycoplasma NEC 041.81operation wound 998.59parotid gland 527.2Peptococcus 041.84Peptostreptococcus 041.84periapical (pulpal origin) 522.4peridental 523.3periodontal 523.3pleuropneumonia-like organisms NEC (PPLO)

041.81pneumococcal NEC 041.2Pneumococcus NEC 041.2postoperative wound 998.59Proprionibacterium 041.84Proteus (mirabilis) (morganii) (vulgaris) NEC

041.6Pseudomonas NEC 041.7salivary duct or gland (any) 527.2seroma 998.51Serratia (marcescens) 041.85staphylococcal NEC 041.10 2

aureus 041.11specified NEC 041.19

streptococcal NEC 041.00 2

Group A 041.01B 041.02C 041.03D [enterococcus] 041.04G 041.05

specified NEC 041.09submaxillary region 528.9 2

thyroglossal duct 529.8tongue NEC 529.0tooth, teeth 522.4

periapical (pulpal origin) 522.4peridental 523.3periodontal 523.3pulp 522.0socket 526.5

Treponema denticola 041.84macrodenticum 041.84

Trichosporon (beigelii) cutaneum 111.2urinary (tract) NEC 599.0 2

Veillonella 041.84Vibrio

vulnificus 041.85virus, viral 079.99 2

unspecified nature or site 079.99 2

wound (local) (posttraumatic) NEC 958.3postoperative 998.59surgical 998.59

Inflammation, inflamed, inflammatory (withexudation)

alveoli (teeth) 526.5gum 523.1jaw (acute) (bone) (chronic) (lower) (suppurative)

(upper) 526.4lip 528.5maxilla, maxillary 526.4mouth 528.0parotid region 686.9 2

gland 527.2salivary duct or gland (any) (suppurative) 527.2tongue 529.0

©2003 Ingenix, Inc. 2 Unspecified E Signs & symptoms K Codes that require a fifth-digit 199

ICD-9-CM Index

Inhalationflame

mouth 947.0Injury 959.9 2

adenoid 959.09alveolar (process) 959.09auditory canal (external) (meatus) 959.09auricle, auris, ear 959.09blood vessel NEC 904.9 2

due to accidental puncture or lacerationduring procedure 998.2

brow 959.09cheek 959.09chin 959.09ear (auricle) (canal) (drum) (external) 959.09epiglottis 959.09Eustachian tube 959.09eyebrow 959.09face (and neck) 959.09forehead 959.09gland

parathyroid 959.09salivary 959.09thyroid 959.09

gum 959.09instrumental (during surgery) 998.2jaw 959.09labyrinth, ear 959.09larynx 959.09lip 959.09malar region 959.09mastoid region 959.09maxilla 959.09membrane

tympanic 959.09middle ear 959.09mouth 959.09nasal (septum) (sinus) 959.09nasopharynx 959.09neck (and face) 959.09nose (septum) 959.09occipital (region) (scalp) 959.09palate (soft) 959.09parathyroid (gland) 959.09parietal (region) (scalp) 959.09pharynx 959.09salivary ducts or glands 959.09scalp 959.09sinus

nasal 959.09submaxillary region 959.09submental region 959.09superficial

tooth, teeth 521.2supraorbital 959.09surgical complication (external or internal site)

998.2temple 959.09temporal region 959.09throat 959.09thyroid (gland) 959.09tongue 959.09tonsil 959.09tooth NEC 873.63

complicated 873.73tympanum, tympanic membrane 959.09uvula 959.09

Insufficiency, insufficientvelopharyngeal

acquired 528.9 2

Interproximal wear 521.1Intertrigo 695.89

labialis 528.5Irradiated enamel (tooth, teeth) 521.8Irregular, irregularity

alveolar process 525.8dentin in pulp 522.3

K Kaposi’s

varicelliform eruption 054.0Keratocyst (dental) 526.0

L Laceration — see also Wound, open, by site

accidental, complicating surgery 998.2tongue 873.64

complicated 873.74Late — see also condition

effect(s) (of) — see also condition fracture (multiple) (injury classifiable to 828-

829) 905.5face and skull (injury classifiable to 800-

804) 905.0skull and face (injury classifiable to 800-

804) 905.0injury (injury classifiable to 959) 908.9 2

blood vessel 908.3head and neck (injury classifiable to

900) 908.3intracranial (injury classifiable to

850-854) 907.0with skull fracture 905.0

intracranial (injury classifiable to 850-854)907.0

with skull fracture (injury classifiable to800-801 and 803-804) 905.0

wound, open head, neck, and trunk (injury classifiable

to 870-879) 906.0Lesion

alveolar process 525.8buccal 528.9 2

intracranial, space-occupying NEC 784.2lip 528.5periodontal, due to traumatic occlusion 523.8salivary gland 527.8

benign lymphoepithelial 527.8space-occupying, intracranial NEC 784.2tooth, teeth 525.8

white spot 521.01white spot, on teeth 521.01

Leukoedema, mouth or tongue 528.7Leukokeratosis (see also Leukoplakia) 702.8

mouth 528.6nicotina palati 528.7tongue 528.6

Leukoplakia 702.8buccal 528.6gingiva 528.6lip 528.6mouth 528.6oral soft tissue (including tongue) (mucosa)

528.6

200 2 Unspecified E Signs & symptoms K Codes that require a fifth-digit ©2003 Ingenix, Inc.


MCM 4107 Pub. 100-4, Chapter 20,Section 30.1.2Pub. 100-4,Chapter 20, Section 100,130, 130.2, 130.3, 130.4,130.5, 130.6,

MCM 4118 Pub. 100-2, Chapter 15,Section 30.5

MCM 4120 Pub. 100-2, Chapter 15,Section 290



MCM 4146. Pub. 100-4, Chapter 12,Section 110.2, 120, 210.1


MCM 4162. Pub. 100-4, Chapter 12,Section 150

MCM 4172 Pub. 100-4, Chapter 12,Section 140, 140.1,140.1.1, 140.1.2, 140.3.4,140.4.2,


MCM 4175 Pub. 100-4, Chapter 11,Section 10, 40, 40.1,40.1.3, 40.2, 40.2.2., 50,120

MCM 4180 Pub. 100-2, Chapter 15,Section 280.2, 280.2.1,280.2.2, 280.2.3, 280.2.4,280.2.5Pub. 100-4,Chapter 18, Section 60,60.1, 60.2, 60.2.1, 60.2.2,60.3, 60.4, 60.5, 60.6,60.7, 60.8

MCM 4182 Pub. 100-4, Chapter 18,Section 50.2, 50.3, 50.3.1,50.4, 50.5, 50.6, 50.7,50.8

MCM 4270 Pub. 100-4, Chapter 8,section 80, 90, 90.3.2,130

MCM 4270.1 Pub. 100-4m Chapter 8,sections 60.4.4, 60.4.4.1,70, 90, 90.1, 90.2, 90.2.1,90.2.2,

MCM 4270.2 Pub. 100-4, Chapter 8,section 60.1, 90

MCM 4273.1 Pub. 100-2, Chapter 11, ,Section 90; Pub. 100-4,Chapter 8, , Section60.4.2, 60.4.2.1

MCM 4277 NCD Manual Section20.20

MCM 4281 NCD Manual, Section70.2.1

MCM 4450 Pub. 100-4, Chapter 20,Section 100.2.2, 100.2.2.3

MCM 4471.2 Pub. 100-4 Chapter 8,Section 120.1

MCM 4480 Pub. 100-4, Chapter 18,Section 10, 10.1, 10.1.1,10.1.2, 10.1.3, 10.2,10.2.1, 10.2.5.2, 10.3

MCM 4601 Pub. 100-2, Chapter 15,Section 280.3Pub. 100-4,Chapter 18, Section 20,20.1, 20.2, 20.2.1, 20.3,20.3.1, 20.3.2, 20.3.2.1,20.3.2.2.


MCM 4603 Pub. 100-2, Chapter 15,Section 280.4Pub. 100-4,Chapter 18, Section 30,30.1, 30.2, 30.3, 30.4,30.5, 30.6, 30.7, 30.8,30.9, 40, 40.1, 40.2, 40.3,40.4, 40.5, 40.6, 40.7



MCM/CIM Refernces


MCM 4830 Pub. 100-4, Chapter 12,Section 50, 140.2

MCM 4900 Pub. 100-2, Chapter

MCM 5112. Pub. 100-4, Chapter 12,Section 160, 160.1, 170,170.1

MCM 5112.1 Pub. 100-4, Chapter 12,Section 160, 160.1, 170,170.1

MCM 5113. Pub. 100-4, Chapter 12,Section 150

MCM 5249 Pub. 100-2, Chapter 15,Section 50.5.1



MCM/CIM ReferencesCoverage Issues ManualCIM 50-26 DENTAL EXAMINATION PRIOR TO

KIDNEY TRANSPLANTATIONDespite the “dental services exclusion” in §1862(a)(12) ofthe Act (see Intermediary Manual,§3162; CarriersManual, §2336), an oral or dental examination performedon an inpatient basis as part of a comprehensive workupprior to renal transplant surgery is a covered service.This is because the purpose of the examination is not forthe care of the teeth or structures directly supporting theteeth. Rather, the examination is for the identification,prior to a complex surgical procedure, of existingmedical problems where the increased possibility ofinfection would not only reduce the chances forsuccessful surgery but would also expose the patient toadditional risks in undergoing such surgery.

Such a dental or oral examination would be coveredunder Part A of the program if performed by a dentist onthe hospital’s staff, or under Part B if performed by aphysician. (When performing a dental or oralexamination, a dentist is not recognized as a physicianunder §1861(r) of the law.)(See Carriers Manual §2020.3.)

Medicare Carriers ManualMCM 2049 Drugs And BiologicalsThe Medicare program provides limited benefits foroutpatient drugs. The program covers drugs that arefurnished “incident to” a physician’s service provided

that the drugs are not usually selfadministered by thepatients who take them.

Generally, drugs and biologicals are covered only if all ofthe following requirements are met:

• They meet the definition of drugs or biologicals(see §2049.1);

• They are of the type that are not usually self-administered by the patients who take them. (See§2049.2);

• They meet all the general requirements forcoverage of items as incident to a physician’sservices (see §§2050.1 and 2050.3);

• They are reasonable and necessary for thediagnosis or treatment of the illness or injury forwhich they are administered according to acceptedstandards of medical practice (see §2049.4);

• They are not excluded as immunizations (see§2049.4.B); and

• They have not been determined by the FDA to beless than effective. (See §2049.4 D.)

Drugs that are usually self-administered by the patient,such as those in pill form, or are used for self-injection,are generally not covered by Part B. However, there area limited number of selfadministered drugs that arecovered because the Medicare statute explicitlyprovides coverage.

Examples of self-administered drugs that are coveredinclude blood clotting factors, drugs used inimmunosuppressive therapy, erythropoietin for dialysispatients, osteoporosis drugs for certain homeboundpatients, and certain oral cancer drugs. (See §§2100.5and 2130.D for coverage of drugs which are necessary tothe effective use of DME or prosthetic devices.)

MCM 2136 Dental ServicesAs indicated under the general exclusions fromcoverage, items, and services in connection with thecare, treatment, filling, removal, or replacement of teethor structures directly supporting the teeth are notcovered. Structures directly supporting the teeth meansthe periodontium, which includes the gingivae,dentogingival junction, periodontal membrane,cementum of the teeth, and alveolar process.

In addition to the following, see §2020.3 and CoverageIssues Manual, §50-26 for specific services which maybe covered when furnished by a dentist. If an otherwisenoncovered procedure or service is performed by adentist as incident to and as an integral part of acovered procedure or service performed by him/her, thetotal service performed by the dentist on such anoccasion is covered.

EXAMPLE 1: The reconstruction of a ridge performedprimarily to prepare the mouth for dentures is anoncovered procedure. However, when thereconstruction of a ridge is performed as a result of andat the same time as the surgical removal of a tumor (for



Coding Guide for Dental Services - Optum360Coding.com Guide Den… · method of translating medical terminology into codes. Codes within the system are either numeric or alphanumeric

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