The Questions and Answers (Q&A) in this publication have been prepared by the ADA
Council on Dental Benefit Programs and are intended to assist a dentist or practice staff
in determining the procedure code that is most appropriate to describe the service
provided. These Q&A complement, but are not part of, the Code on Dental Procedures
and Nomenclature (Code) that is published in Section 1 of this CDT manual. Q&A are not
to be considered legal advice or a guarantee that individual payer contracts will follow
this assistance.
Questions and their answers on the Code in the following pages are distributed across
the twelve categories of service (e.g., Diagnostic; Restorative). Where appropriate,
some Q&A’s are grouped within a subcategory of service. Each of the questions and
their answers reflects actual inquires from dentists and their staff.
3. What are the codes for an initial exam and an emergency exam?
A series of clinical evaluation codes exist that recognize the cognitive skills
necessary for patient evaluation. Codes D0120 through D0180 are available
to report patient evaluations, depending on the nature of the service provided.
Please refer to the code’s nomenclature and descriptor to assist your decision
making process.
The initial examination for a new patient may be reported using “D0150
comprehensive oral evaluation – new or established patient” or by “D0180
comprehensive periodontal evaluation – new or established patient.” An
examination of a patient who presents with a dental emergency may be reported
using “D0140 limited oral evaluation – problem focused.”
4. Can I submit a periodic evaluation (D0120) on the same day as a full mouth
debridement to enable comprehensive periodontal evaluation and diagnosis
(D4355)?
There is nothing in the descriptors of the oral evaluation code or D4355 that
preclude reporting on the same day. Some benefit plans have limitations or
exclusions about paying for both of these procedures on the same day.
7. We recently had a patient come in for a periodic oral evaluation. The
doctor found signs and symptoms of periodontal disease and performed
a complete periodontal evaluation. May I report both the periodic and
periodontal evaluations, since these are two separate procedures?
The comprehensive periodontal procedure includes all of the components of a
periodic evaluation, and adds additional requirements for periodontal charting and
the evaluation of periodontal conditions. When a patient presents with signs or
symptoms of periodontal disease, and all of these components were performed,
D0180 would be reported.
Radiographs/Diagnostic Imaging
11. Are a panoramic films and bitewings considered a full mouth series of
radiographs?
No, a panoramic film and bitewings are not the same as the “D0210 intraoral,
complete series…” procedure. According to the FDA’s “The Selection of Patients
for Dental Radiographic Examinations” published in 2005, a full mouth series is
defined as “A set of intraoral radiographs usually consisting of 14 to 22 periapical
and posterior bitewing images intended to display the crowns and roots of all
teeth, periapical areas and alveolar bone crest.” Effective January 1, 2009 this
definition was incorporated into the D0210 descriptor.
Further, a panoramic film cannot be considered a full mouth series as it is an
extraoral film and it does not reflect the FDA definition of a full mouth series.
Different procedure codes are available to report a full mouth series (D0210)
and a panoramic film (D0330). Please note that bitewings taken as part of a
full mouth series are not reported separately.
12. There are procedure codes for one, two and four bitewings, but no code
for three bitewings. How do I report three bitewing x-rays?
A procedure code to report three bitewing images was approved by the Code
Revision Committee effective January 1, 2007. You may report procedure code
“D0273 bitewings, three films.”
13. Our office has begun to use new technology that provides 3-D or 2-D images
of a patient that are generated from a CT-like scan. How do we code this?
Three procedure codes are available. To report the patient visit when the images
are taken, use code “D0360 cone beam ct – craniofacial data capture.”
If a traditional two dimensional view is produced, such as a panoramic image or
lateral skull, report “D0362 cone beam – two dimensional image reconstruction
using existing data, includes multiple images.”
When a three-dimensional view is generated, use code “D0363 cone beam – three
dimensional image reconstruction using existing data, includes multiple images.”
15. Is a caries susceptibility test (D0425) the same as a caries detectibility
test?
No, they are different procedures. A caries susceptibility test is a diagnostic test
for determining a patient’s propensity for caries. There is no procedure code for
a caries detectibility test, which aids in determining the presence of caries.
“D0999 unspecified diagnostic procedure, by report” may be used to report a
caries detectibility test.
16. Can I submit a code for pulp vitality tests or is this considered to be
included in all endodontic procedures?
Yes, you may submit this as a separate service (D0460) as it is a stand-alone
code. It includes multiple teeth and contra lateral comparison(s), as indicated.
17. Our office recently purchased a VelScope and was wondering if there was
a procedure code available?
Procedure codes contained in the Code on Dental Procedures and Nomenclature
as published by the ADA in the CDT manual are not product or brand-name
specific. Devices such as the VelScope may be used in the delivery of procedures
such as: “D0431 adjunctive pre-diagnostic test that aids in detection of mucosal
abnormalities including premalignant and malignant lesions, not to include
cytology or biopsy procedures.”
Dental Prophylaxis
6. Can “D1110 prophylaxis-adult” and “D4342 scaling and root planing one
to three teeth per quadrant” be reported on the same date of service?
There is no language in the descriptor of an adult prophylaxis that precludes
the reporting of any other procedure. Some benefit plans have limitations or
exclusions about paying for both these procedures on the same day.
7. Our office has received EOB’s from insurance companies indicating that
the combination prophy/fluoride codes (D1201-child, D1205-adult) are
no longer valid. What are the new combination codes?
The Code does not contain combination prophy/fluoride procedure codes.
Effective January 1, 2007 a prophylaxis and a fluoride treatment are reported
as two separate procedures. For a child codes “D1120 prophylaxis – child” and
“D1203 topical application of fluoride-child” may be reported. For an adult codes
“D1110 prophylaxis – adult” and “D1204 topical application of fluoride – adult”
may be reported.
8. I see that there is a code for placing fluoride varnish. May I use this code
when applying varnish to desensitize a tooth?
When fluoride varnish is utilized to desensitize a tooth, you may report “D9910
application of desensitizing medicament”. Procedure code “D1206 topical
fluoride varnish; therapeutic application for patients at moderate to high risk
of developing caries” is used for therapeutic purposes with patients who are at
moderate to high risk of developing caries.
9. If our office uses fluoride varnish as part of our recall visit protocol should
I report codes D1203 or D1204 as we have done in the past, or should I
use the new fluoride varnish code?
The procedure codes you have used in the past for preventive topical fluoride
(D1203 and D1204) do not specify the formulation or technique used for
application. Procedure code D1206 should be reported for the therapeutic
application of fluoride varnish for patients with moderate to high risk of caries
development.
13. When using resin, what distinguishes a sealant from a preventive resin
restoration?
The Code was revised effective January 1, 2011 to enable separate reporting of
these distinct procedures. Resin used as a sealant in a pit and fissure area, limited
to the enamel, would be documented using D1351. When resin is used in a pit and
fissure area where there is an active cavitated lesion that does not extend into the
dentin, the available procedure code is D1352 (added effective January 1, 2011).
Should the lesion extend into the dentin, the procedure code for one surface
composite resin restoration (D2391) would be used to document the service.
As always, the full procedure code nomenclature and descriptor must be used to
determine which Code entry is applicable.
D1351 sealant - per tooth
Mechanically and/or chemically prepared enamel surface sealed to
prevent decay.
D1352 preventive resin restoration in a moderate to high caries risk
patient – permanent tooth
Conservative restoration of an active cavitated lesion in a pit or
fissure that does not extend into dentin; includes placement of
a sealant in any radiating non-carious fissures or pits.
D2391 resin-based composite – one surface, posterior
Used to restore a carious lesion into the dentin or a deeply eroded
area into the dentin. Not a preventive procedure.
4. I recently purchased a laser and have been unable to find any “laser” codes
in the Code on Dental Procedures and Nomenclature.
The codes are procedure based rather then instrument based. You would report
the appropriate code based on the actual procedure that was performed.
6. Should single crowns that are splinted together be coded as single crowns
(in the D27xx series of codes) or as a bridge (in the D67xx series)?
Single crowns that are splinted together are appropriately reported as single
crowns, D27xx. There is no coding mechanism to report splinting the crowns.
Prosthodontic retainers are parts of a fixed partial denture that attach a pontic
to the abutment tooth, implant abutment, or implant and should be used in
conjunction with a pontic code.
8. How do I code a porcelain fused to titanium crown? I only see a code for
titanium code D2794 crown - titanium.
“D2794 crown – titanium” is the only titanium crown procedure available.
9. Is there a code for retrofitting a new crown to an existing partial denture?
The code is “D2971 additional procedures to construct new crown under existing
partial denture framework” and should be reported in addition to the crown.
11. Code “D2970 – temporary crown (fractured tooth)” was deleted from the
version of the Code published in CDT-2005. What code is the replacement
for D2970?
The Code Revision Committee reinstated a revised code D2970 effective
January 1, 2007 and published in the CDT manual.
14. The patient’s treatment plan includes placement of a prefabricated post and
core under an existing crown. What procedure code would be used to report
this procedure?
There is no code that specifically refers to placement of a prefabricated post and
core under an existing crown. When there is no procedure code whose nomenclature
and descriptor reflect the service provided, an “unspecified…procedure, by report”
code may be considered (e.g., D2999 unspecified restorative procedure, by report).
16. An access cavity was made through a crown for endodontic treatment.
What procedure code is appropriate to report sealing an endodontic
access cavity?
There is no code that specifically refers to placement of a restoration to seal an
endodontic access cavity. When there is no procedure code whose nomenclature
and descriptor reflect the service provided, an “unspecified…procedure, by report”
code may be considered (e.g., D2999 unspecified restorative procedure, by
report). Restorative codes may also be used to report sealing an access cavity.
Pulpotomy
Endodontic Therapy
2. Should I report a root canal procedure on the date the tooth is opened,
or the final fill date?
For clinical record keeping purposes, the initiation date should be recorded.
Some third-party payers require the completion date as the date of service
for an endodontic procedure.
3. If I see a patient on an emergency basis to relieve pain and begin a root
canal procedure on tooth # 31, but do not finish it on the same day, may
I code D3221 on the initial visit and later code the root canal procedure
(D3330)?
Language in the descriptor of pulpal debridement (D3221) precludes the same
provider from reporting this procedure on the same date as an endodontic
procedure. Since the date of completion of the root canal is different from the
date of initiation of the procedure, and the patient presented with an emergency,
both codes may be reported.
4. What code do I use to report root canal therapy on a molar with 4 canals
since it requires more work than a typical molar with three roots?
Endodontic therapy is reported based on the anatomic type of the tooth, not
number of canals. Code “D3330 endodontic therapy, molar (excluding final
restoration)” should be reported for a molar root canal therapy.
Apicoectomy/Periradicular Services
9. If I perform an apicoectomy and submit tissue for a biopsy on tooth #10,
how do I code for these procedures?
Submission of tissue for biopsy is not included in the subcategory descriptor as
a component of an apicoectomy procedure. There are no biopsy codes available
to report tissue collection during an apicoectomy procedure. The descriptor of
“D7286 biopsy of oral tissue – soft” prohibits its use at the same time as codes
for apicoectomy/periradiucular surgery. An available code is “D9999 unspecified
adjunctive procedure, by report”. Plan limitations may exclude or not recognize
certain combinations of codes performed on the same day.
10. I am a dentist in general practice and my patient has a tooth that needs
endodontic retreatment, which will be provided by an endodontist after
I remove the post. What procedure code is appropriate to report only
removal of the post?
“D2955 post removal (not in conjunction with endodontic therapy)” may
be reported because the post removal is by a different practitioner than the
retreating dentist.
Surgical Services
6. Can D1110 (adult prophylaxis) and D4342 (scaling and root planing one to
three teeth) be reported on the same date of service?
There is nothing in either codes’ nomenclature or descriptor that says these two
cannot be reported on the same day. However, many benefit plans are designed
not to allow payment of benefits for these procedures when reported on the
same date of service.
7. We use the bone replacement graft codes D4263 and D4264 in periodontal
defects around and adjacent to natural teeth. Do we use the same codes in
periodontal defects around existing endosseous implants?
There is nothing in either code’s nomenclature or descriptor that says these two
cannot be used to report grafts around existing endosseous implants. Should a
dentist, after considering nomenclatures and descriptors, determine that neither
code appropriately describes the service provided an ‘unspecified procedure,
by report’ code may be used (e.g., “D4999 unspecified periodontal procedure,
by report”).
8. We use the bone replacement graft code D7953 when placing graft
material in an extraction socket when we remove a natural tooth. But
if we place an immediate implant in the extraction site and place bone
graft around the implant, do we still use D7953 or do we use one of the
periodontal bone graft codes D4263 or D4264?
The nomenclature for D7953 indicates that this procedure code is appropriate
to report when the service is for ridge preservation, and this code’s descriptor
9. If we remove an existing implant and place bone replacement graft in the
site, can we still use the D7953 code?
The descriptor for D7953 states that the graft “…is place in an extraction site
at the time of extraction….” This indicates that “D7953 bone replacement graft
for ridge preservation - per site” may not be appropriate to report the service as
described because the literal definition of extraction applies to a tooth.
When a dentist determines, after considering nomenclatures and descriptors,
no code appropriately describes the service provided an “unspecified…procedure,
by report” code may be used (e.g., “D7999 unspecified oral surgery procedure,
by report”).
10. The dental hygienists in our office are using Oraqix prior to scaling and root
planing. How would Oraqix be reported?
The Periodontics category of service indicates that “Local anesthesia is usually
considered to be part of Periodontal procedures.” However, there is nothing to
prevent reporting the use of Oraqix to anesthetize the patient with procedure
code “D9215 local anesthesia in conjunction with operative or surgical
procedures.” Benefit plan limitations may exclude separate reimbursement for
local anesthesia.
18. Can “D4910 periodontal maintenance” and “D4342 scaling and root planing
one to three teeth per quadrant” be reported on the same date of service?
The descriptor of code D4910 indicates that it includes site specific scaling and
root planing where indicated. Scaling and root planing performed as part of the
maintenance procedure should not be reported separately. However, if new or
recurring periodontal disease appears at the time of the maintenance procedure,
additional diagnostic and treatment procedures must be considered. Plan limitations
may exclude or not recognize certain combinations of codes performed on the
same day.
Complete Dentures
1. What is the code for a complete upper denture with a cast metal palate?
Code D5110 (complete denture – maxillary) may be reported. The code is silent
in regard to the type of materials used in fabrication.
Partial Dentures
Interim Prostheses
2. How do I code resilient implant attachments (e.g., ERA, ZAAG, Zest) done
in conjunction with an implant overdenture?
A resilient implant attachment may be reported using code “D5862 precision
attachment, by report.” Each set of male and female components should be reported
as one precision attachment. The type of attachment used should be described.
If one of the components (male or female) is an integral part of an abutment,
the applicable implant abutment procedure code (e.g., D6056, D6057) may be
reported in addition to “D5862 precision attachment, by report.
3. There are no pontic codes in the Implant category of the Code. When
reporting a fixed partial denture placed on implants, how do I report a pontic?
Pontic codes, found in the Fixed Prosthodontic category of the Code, can be used
with both implant and Fixed Prosthodontic retainer codes. All pontic codes begin
with D62xx.
Pre-Surgical Services
Surgical Services
10. We have several patients that have implant supported mandibular complete
dentures. What procedure code would be used to report cleaning of the
implants?
Procedure code “D6080 implant maintenance procedures, including removal of
prosthesis, cleansing of prosthesis and abutments and reinsertion of prosthesis”
in the Code on Dental Procedures and Nomenclature would apply to the situation.
The descriptor for this code reads as follows:
“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.”
6. Our office filed a claim for a three unit bridge. One of the abutments needed
a root canal and post and core. The claim was rejected by the payer because
we used code D2952 instead of D6970 to report the post. What is the
difference between the two codes?
The two procedures are identical. The only difference is that one procedure code
is reported when a single crown will be placed (D2952), and the other procedure
code is reported when a fixed bridge will be placed (D6970).
Extractions
2. I removed a portion of the patient’s fractured tooth, but not the entire
tooth, to provide immediate relief of pain. How should I report this
procedure?
There is no code that specifically refers to removal of a portion of a fractured
tooth to relieve pain. When there is no procedure code whose nomenclature and
descriptor reflect the service provided, an “unspecified…procedure, by report” code
may be considered (e.g., “D7999 unspecified oral surgery procedure, by report”).
Surgical Extractions
12. What is the difference between code “D4263 bone replacement graft –
first site in quadrant”, code “D7950 osseous, periosteal, or cartilage graft
of the mandible or maxilla – autogenous or nonautogenous, by report” and
code “D7953 bone replacement graft for ridge preservation – per site?”
Code D4263 should be reported when the bone graft is performed to stimulate
periodontal regeneration when the disease process has led to a deformity of the
bone around an existing tooth. Code D7953 should be reported when the bone
graft is placed in an extraction site at the time of the extraction to preserve
ridge integrity. Code D7950 should be reported when the graft is used for
augmentation or reconstruction of an edentulous area of a ridge.
13. How do I code the use of collagen wound dressing products that promote
hemostasis (blood clotting)?
There is no procedure code for collagen wound dressing products. Use of collagen
may be a component of a procedure such as “D9930 treatment of complications
(post-surgical) – unusual circumstances, by report.” In other circumstances,
depending on the primary procedure performed, code “D7999 unspecified oral
surgery procedure, by report” or “D4999 unspecified periodontal procedure,
by report” may be reported.
14. Sinus lift procedures could be reported using code D7950 as published
in CDT 2005, but I noticed that this procedure was removed when code
D7950 was revised for the version published in CDT 2007/2008.
How can I report a sinus lift procedure?
A new code to report sinus lift procedures was introduced in the version of the
Code effective January 1, 2007 and first published in CDT 2007-2008.
Report code “D7951 sinus augmentation with bone or bone substitutes.”
15. We do implants in our office and don’t always place the grafting material
at the time of a tooth extraction; sometimes it is placed at a later date.
What procedure code would be appropriate to report this service?
Procedure code D7950 may be reported when grafting material is being placed
at any time and when placement is not in an extraction site.
18. The dentist performed a frenectomy on a child that had been diagnosed
with ankyloglossia. What is ankyloglossia and how would treatment be
documented?
Ankyloglossia, more commonly referred to as “tongue tied,” is a condition in which
the lingual frenum is short and attached to the tip of the tongue, making normal
speech difficult.
Available procedure code:
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 buccal, labial or
lingual frenum that is associated with a pathological condition, or interferes with
proper oral development or treatment.
19. Prior to the replacement of an ill filling maxillary complete denture, it was
necessary to surgically remove an excess formation of palatal tissue. How
would this procedure be documented?
Available procedure code:
D7970 excision of hyperplastic tissue – per arch
5. What is the procedure code for placement of a band and loop space
maintainer?
The space maintainer codes are listed under the Preventive category of service.
A band and loop would be reported as “D1510 space maintainer – fixed –
unilateral.”
Unclassified Treatment
Anesthesia
3. Our office used code D9610 (therapeutic drug injection) to report injection
of sedative agents. As of January 1, 2007 D9610 was revised to prohibit
the reporting of sedative agents. How should the injection of sedative
agents be reported?
Available codes are “D9230 inhalation of nitrous oxide / anxiolysis, analgesia” or
“D9248 non-intravenous conscious sedation.”
Professional Consultation
Code D0140 and D0160 are both problem focused evaluations. D0160 should
be used when the evaluation is detailed and extensive, and based on the findings
of a comprehensive evaluation.
Professional Visits
6. If a practitioner treats more than one patient in one nursing home on one
day, is D9410 (house/extended care facility call) reported per patient or
per facility?
The descriptor for code D9410 states that it may be reported in addition to
separate reporting of services provided to a patient seen at the facility. D9410
may be reported for each patient receiving service at the facility on a given day.
7. Is “D9420 hospital or ambulatory surgical center call” to be used for each
patient seen in the facility setting, or is it to be reported once when a dentist
sets a block of time (e.g., half day) aside when several patients may be seen?
The descriptor for D9240 states that services provided to the patient on the date
of service are documented separately. D9420 may be reported for each patient
receiving service at the hospital on a given day.
Drugs
8. Is “D9630 other drugs and/or medicaments, by report” only for medicaments
dispensed in the office for home use, or can this be reported for drugs or
medicaments used in the dental office?
There is some ambiguity in the first part of the descriptor for code D9630, which
reads as follows: “Includes but is not limited to oral antibiotics, oral analgesics
and topical fluoride that are dispensed in the office for home use; ....” Some may
argue that the phrase “…dispensed in the office for home use…” applies only to
topical fluoride. Others may argue that the descriptor means this procedure code
Miscellaneous Services
10. Are professional strength at-home teeth whitening and bleaching systems
delivered in the office reportable under code “D9972 external bleaching –
per arch”?
You may report code D9972 as there is no limitation on the material that may
be used to provide the service.
12. After placing an occlusal guard I have patients return for approximately
3-4 office visits, as needed, to adjust the guard. What procedure code
would be used to report visits to adjust the guard?
The Code does not contain a specific code for adjusting an occlusal guard. An
available code would be “D9999 unspecified adjunctive procedure, by report.”
13. Does the “external” in the external bleaching code refer to home bleaching,
and the ‘internal’ in the internal bleaching code refer to bleaching
performed in the office?
“External” refers to the outer surface of a tooth, or the entire arch. “Internal”
refers to bleaching performed inside the pulp chamber of a tooth.
15. A patient is having porcelain veneers placed on teeth 6 through 11. The
dentist is having the laboratory make a diagnostic wax-up. What is a
diagnostic wax up and how would it be documented?
A diagnostic wax-up presents the patient with a natural-looking, three dimensional
representation of the final case. Also, through the diagnostic wax –up, the dentist
can obtain a visual understanding of tooth reduction requirements.
Available procedure code:
D9950 occlusal analysis –mounted case
Includes, but is not limited to, facebow, interocclusal records tracings,
and diagnostic wax-up; for diagnostic casts, see D0470.
2. The list of provider specialty codes that is printed on the back of the paper
claim form, and in the detailed claim form completion instructions published
in the CDT manual appears to have two codes that describe a general dentist.
As a general practitioner should I use the code for a Dentist (122300000X)
or the code for General Practice (1223G0001X)?
Provider specialty codes (Item #56A) listed on the form and in the CDT manual
reflect the architecture of this code set. The code for Dentist (G122300000X)
may be used by any practitioner who does not wish to be uniquely identified as in
general practice or in specialty practice. Provider specialty code 1223G0001X is
intended to be used by any dentist who wishes to be identified as one who is in
General Practice.
3. I’m filing a claim with my patient’s medical benefit plan. How do I complete
the ADA Dental Claim Form to do this?
Claims filed against a patient’s medical benefit plan do not use the ADA Dental
Claim Form.
4. What form do I use to file a claim with my patient’s medical benefit plan?
Medical benefit plan claims use the “1500 Health Insurance Claim Form” for paper
submissions, or HIPAA electronic equivalent. Information on the 1500 Health
Insurance Claim Form, including completion instructions, are published by an
agency of the American Medical Association and can be found on-line at: www.
nucc.org. The ADA recommends contacting your practice management system
vendor for information and assistance on submission of electronic medical claims.
6. In the past, our office has always used UR, UL, LR, and LL to indicate the
area of the oral cavity. I have heard that these symbols are not being used
any longer. Is this correct?
Yes, the Area of the Oral Cavity is now designated by a two-digit numeric code,
which is a HIPAA standard. This code is placed in Item 25 of the current ADA
paper claim form (2006 © American Dental Association). Completion instructions
for this field, as published in the CDT manual, follow:
25. Area of Oral Cavity: Use of this field is conditional. Always report the
area of the oral cavity unless one of the following conditions in Item #29
(Procedure Code) exists:
• The procedure identified in #29 requires the identification of a tooth
or a range of teeth.
• The procedure identified in #29 incorporates a specific area of the oral
cavity in its nomenclature (for example, D5110 complete denture –
maxillary).
• The procedure identified in #29 does not relate to any portion of the
oral cavity (for example, D5914 auricular prosthesis, or D9220 deep
sedation/general anesthesia – first 30 minutes).
Area of the oral cavity is designated by a two-digit code, selected from the
following code list:
Code Area
00 entire oral cavity
01 maxillary arch
02 mandibular arch
10 upper right quadrant
20 upper left quadrant
30 lower left quadrant
40 lower right quadrant
Exclusions / Limitations
1. A patient is missing teeth 4,5,12 and 14. The dentist’s treatment plan
includes a bilateral removable partial denture. The insurance company denied
the partial because the teeth were extracted prior to the effective date of
the insurance policy. I don’t understand why the partial was denied.
Some group health plans restrict coverage for dental conditions present before
an individual’s enrollment in the plan, such as missing teeth. These restrictions
are known as “pre-existing conditions” exclusions.
Pre-existing condition exclusion may also be called a “waiting period” and
the length of time before coverage is available is specified in the benefit plan
documents. Times can vary and the patient should contact their employer or
insurance carrier for more information.
Please remember – dental benefit plan coverage limitation & exclusions, and
where applicable the provisions of a participating provider agreement, affect
third-party claim adjudication.
2. Dental benefit plan coverage limitation & exclusions, and where applicable
the provisions of a participating provider agreement, affect third-party
claim adjudication. Sometimes how a payer adjudicates a claim appears
inconsistent with the ADA’s message – “code for what you do.”
Example #1:
The dentist reports “D2391 resin-based composite – one surface, posterior”
on tooth #18. A payer may adjudicate the claim using “D2140 amalgam –
one surface, primary or permanent” when the benefit contract makes an
allowance equivalent to an amalgam restoration on posterior teeth.
If this happens the Explanation of Benefits (EOB) should clearly give the
reasons for the action and not state or imply that the dentist filed the claim
incorrectly.
Please remember – dental benefit plan coverage limitation & exclusions, and
where applicable the provisions of a participating provider agreement, affect
third-party claim adjudication.
Example #2:
A patient is missing teeth 3,4,12 and 13. The dentist’s treatment plan
includes two- four unit fixed partial dentures. When the claim is adjudicated,
the benefit contract makes an allowance equivalent to a removable bilateral
partial denture. This is an example of a benefit contract containing a least
expensive alternative treatment (LEAT) clause.
LEAT is a contractual limitation that will only allow benefits for the least
expensive treatment when there are multiple treatment options for a specific
condition. LEAT does not determine treatment, but does determine level of
benefits available.
Again, if this happens the Explanation of Benefits (EOB) should clearly give
the reasons for the action and not state or imply that the dentist filed the
claim incorrectly.
Please remember – dental benefit plan coverage limitation & exclusions, and
where applicable the provisions of a participating provider agreement, affect
third-party claim adjudication.