www.optumcoding.com Dental Services SAMPLE

1 Full suite of resources including the latest code set, mapping products, and expert training to help you make a smooth transition. ServicesAn essential coding , billing , and reimbursement resource for Dental servicesCoding andPayment GuideSAMPLE 2016 Optum360, LLC 2015 American Medical Association. All Rights systems and claim forms are the realities of modern health care and have evolved to become the basis of reimbursement for health care Services . coding and Payment Guide for Dental Services provides a comprehensive look at the coding and reimbursement systems used by dentists. It is organized topically and numerically, and can be used as a comprehensive coding and reimbursement resource and as a quick look-up resource for SystemsThe coding systems discussed in this coding and Payment Guide for Dental Services seek to answer two questions: what was wrong with the patient ( , the diagnosis or diagnoses), and what was done to treat the patient ( , the procedures or Services rendered).

2 The Centers for Medicare and Medicaid Services (CMS), in conjunction with the American Medical Association (AMA), the American Dental Association (ADA), and several other professional groups, has developed, adopted, and implemented a two-level coding system describing Services rendered to the Current Procedural Terminology, Fourth Edition (CPT , HCPCSL evel I), the Healthcare Common Procedure coding System (HCPCS Level II), and the Current Dental Terminology (CDT) codes are used to indicate what Services or supplies were rendered and which procedures were performed during the patient s CodesThe Current Dental Terminology (CDT) codes are developed by the American Dental Association (ADA). It should be noted that the CDT code book as published by the ADA contains a number of components, such as the Code on Dental Procedures and Nomenclature (Code) and instructions for use of the Code that are not found in HCPCS Level II. The CDT codes provide the Dental profession with a standardized coding system to document and communicate accurate information about Dental treatment procedures and Services to third-party payers.

3 Beginning January 2013, the CDT code system is updated Level I or CPT CodesCPT codes are the most commonly used coding system for reporting outpatient Services and codes are published annually and copyrighted by the AMA. CPT codes predominantly describe medical Services and procedures and have been adapted to provide a common billing language that providers and payers can use for payment purposes. CPT codes are primarily used by dentists when indicating Services such as gingivectomy or gingivoplasty. They are required for billing by both private and public insurance payers, managed care companies, and workers compensation AMA makes periodic changes to codes and their descriptions. These changes are posted on the AMA s website with the date these code changes are effective. Most code changes by the AMA occur annually. The panel accepts information and feedback by providers about new codes and revisions to existing codes that could better reflect the service or procedure being Level II CodesHCPCS Level II codes are commonly referred to as national codes or by the acronym HCPCS (Healthcare Common Procedure coding System pronounced hik piks ).

4 HCPCS codes are used for billing Medicare and Medicaid patients and have also been adopted by some third-party to January 1, 2011, the HCPCS Level II coding system contained the Current Dental Terminology (CDT) codes. Per an updated license agreement between the American Dental Association and CMS, effective January 1, 2011, CMS no longer includes the D codes in the free downloadable HCPCS file. It should be noted, however, that some private publishers are still including the CDT codes within their HCPCS Level II CodesIn response to ICD-9-CM s shortcomings, new coding systems were developed and have been implemented in the United States. The World Health Organization (WHO) created and adopted ICD-10 in 1994 and it has been used in much of the world since then. This system is the basis for the new diagnosis coding system, International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) effective October 1, ICD-10-CM coding system is an alphanumeric system and allows for up to seven characters to be assigned to describe a disease or injury.

5 Generally, the reason the patient seeks treatment should be sequenced first when multiple diagnoses are , the 10th revision goes into greater clinical detail than ICD-9-CM and addresses information about previously classified diseases, as well as those diseases discovered since the last revision. Conditions are grouped with general epidemiological purposes and the evaluation of health care in mind. New features have been added, and conditions have been reorganized, although the format and conventions of the classification remain unchanged for the most of these revisions include: Information relevant to ambulatory and managed care encounters Expanded injury codes Creation of combination diagnosis/symptom codes to reduce thenumber of codes needed to fully describe a condition The addition of sixth- and seventh-character subclassifications Incorporation of common fourth- and fifth-character subclassifications Classifications specific to laterality Classification refinement for increased data granularity This new structure also allows for further expansion than was possible with the ICD-9-CM classification system.

6 Claim FormsNoninstitutional providers and suppliers (private practice or other health care providers offices) use the CMS-1500 form to submit claims to Medicare contractors for Medicare Part B-covered Services . Medicare SAMPLED2790-D2792crown - full cast high noble metalD2790crown - full cast predominantly base metalD2791crown - full cast noble metalD2792 ExplanationA crown is a restorative cap for a tooth made in exact reproduction to the tooth'sanatomy. The dentist takes an upper and lower bite impression of the section ofthe mouth containing the tooth to be crowned and sends it to the lab. Plaster ispoured into the impression mold with pins placed for later removal, connected toan articulator with more plaster, and then the poured model is removed. Theprepped tooth is isolated. The margins are trimmed and marked. A spacer substanceis painted on to the exact allowance needed for cementing the crown onto thetooth. A wax model is made of the full crown over the die model of the tooth,removed, and encased with a channel in high-density plaster.

7 The wax is burnedout. The model is filled with molten metal, spun on the arm of a centrifuge. Thecast metal crown is tested on the tooth model, shaped, polished, and sent backto the dentist who tries the crown on the patient, checks all contact points andmargins, then cements the crown onto the tooth. Report D2790 for a full cast highnoble metal crown, D2791 for a full cast predominantly base metal crown, andD2792 for a full cast noble metal TipsLocal anesthesia is included in these Services . Any evaluation, radiograph, rootcanal, core buildup, or post or preparation service is reported separately. Toothnumbering and preoperative periapical x-rays may be required by some third-partypayers. To report 3/4 cast metal crowns see, D2780 D2782. Crowns made with aresin are reported using codes D2710 D2722. Porcelain crowns are reported withD2740 D2752. High noble metals include gold, palladium, and platinum. Thecontent must be 60 percent gold plus platinum and 40 percent gold.

8 Noblemetals include 25 percent or less gold plus platinum group. Predominantly basealloys contain a noble metal content of < 25 percent gold plus platinum metals of the platinum group include platinum, palladium, rhodium, iridium,osmium, and ruthenium. Resin-based composite includes fiber or ceramicreinforced polymer compounds. Porcelain/ceramic refers to pressed, fired, polished,or milled substances, which predominantly contain inorganic refractory compoundssuch as porcelains, glasses, ceramics, and glass-ceramics. Report prefabricatedstainless steel crown restorations using D2930 D2931, D2933, or TipsTreatment plan documentation should reflect any treatment failure or change indiagnosis and/or a change in treatment plan. There should also be evidence ofany initiation or reinstatement of a drug regime, which requires close andcontinuous skilled medical observation. The following information can bedocumented on a tooth chart: treatment/location of caries, endodontic procedures,prosthetic Services , preventive Services , treatment of lesions and Dental disease,or other special procedures.

9 A tooth chart may also be used to identify structureand rationale of disease process and the type of service performed on intraoralstructures other than TipsThird-party payers often consider laboratory costs, tooth preparation, pulp caps,temporary restorations, porcelain margins, cement bases, impressions, and localanesthesia to be components of a complete restoration and, therefore, will notmake separate payment for these Services . Third-party payers may consider thebuildup under a crown as included in the fee for a crown. A payer may allow anexception where extensive buildup is needed to gain retention and make additionalpayment in these instances. When this occurs, a written report and x-rays shouldbe submitted with the claim. However, most payers will not reimburse separatelyfor a buildup when placed to remove undercuts or to add bulk to the may require documentation including the tooth number, surface(s), andpreoperative periapical To Knowartificial dentistry, a ceramic or metal restoration made to cover or replacea major part of the top of a dentistry, two or more components connected by chemical adhesion ormechanical covering that is placed over a tooth before attaching a crown or of an anatomical structure formed via a negative impression in waxor soft tissue, or pulp, of the tooth containing the lymph vessels, veins,arteries, and nerves of the tooth within small channels (up to five) running from the top ofthe tooth down to the tip of the root.

10 When the tooth is cracked or decayed, bacteria enterthe pulp and infect it, causing damage or death to the pulpal tissue and possibly an abscessthat can infect bone. Root canal therapy repairs the root canal by removing the damagedpulp and cleaning out bacteria to prevent further damage and save the CodesN/AICD-10-CM Diagnostic CodesDental caries on pit and fissure surface penetrating into caries on pit and fissure surface penetrating into caries on smooth surface limited to caries on smooth surface penetrating into caries on smooth surface penetrating into root caries, attrition of of of note that this list of associated ICD-10-CM codes is not all-inclusive. Theprocedure may be performed for reasons other than those listed that support themedical necessity of the service. Only those conditions supported by the medicalrecord documentation should be EditsMUES tatusFUDNon-Fac RVUFac RVU- ReferencesModifiersNoneN/AN/AN/AN/AD2790 N/AN/AN/AN/AD2791N/AN/AN/AN/AD2792* with documentation 2016 Optum360, LLCT hese CDT RVUs are not developed by CMS.