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ADA creates new committee, process to maintain CDT Code

Dr. Richeson

The ADA Council on Dental Benefit Programs is launching a new process to maintain the CDT Code.

The goal is to allow the Code to be more responsive to the needs of the profession and the public, said Dr. Jim Richeson, CDBP chair. CDBP is reaching out to all stakeholders, including third-party payers and dental specialty organizations. 

“At the forefront of the council's thinking, as they fulfill their ADA Bylaws responsibilities for maintaining the Code on Dental Procedures and Nomenclature, is to consider all points of view before making decisions,” Dr. Richeson said. During the past decade, decisions on changes to the CDT Code have been made by the Code Revision Committee, in accordance with the initial term of a legal settlement agreement. That settlement agreement remains in effect, but the parties have moved into a different term of the agreement, where there is no provision for the CRC.

A new committee is being formed, called the Code Advisory Committee, which will provide a forum for testimony and discussion regarding code change requests from all stakeholders. Its first meeting is scheduled for Feb. 10-11 at ADA Headquarters.

During the period when the CRC was responsible for approving changes to the Code, complaints arose from both dentists and third-party payers that the Code was not adequately responsive to an evolving profession.

The nature of the process also created a situation where deadlock because of even minor differences between the participants was common, Dr. Richeson said.

“This was not an optimal process to promote dialogue, and it did not provide for an efficient mechanism to move ahead with changes to the Code when any differences of opinion remained. The primary purpose of the CDT Code is to achieve uniformity, consistency and specificity in accurately reporting dental treatment,” Dr. Richeson said.

The CDT Code also provides for the efficient processing of dental claims. The CDT Code supports documentation on patient records—paper and electronic—as well as on claim submission and adjudication.

The ADA has always maintained the viewpoint that the CDT Code should have sufficient detail to accurately document services provided. Gaps in the CDT Code are identified when a dentist is forced to record a code that only comes close to correctly describing the service rendered, or must use an unspecified code, usually with the last three digits being 999. “Since claims data is mined for numerous purposes, accuracy and specificity in the CDT Code are essential,” Dr. Richeson said.

A code set that provides specificity is also needed to allow dentists to code for what they do. This has always been the position of the ADA; that dentists must accurately code for the procedure that is performed, not for any other reason, including maximizing claims adjudication. It is only possible to fulfill that mandate if the code set provides the means to accurately and specifically code for what a dentist does. Having an accurate code for each procedure performed does not mean that there will be a third-party payer benefit provided for the procedure, Dr. Richeson said. This is consistent with the stated purpose of the CDT Code. All procedures need a means to record and report them but not all procedures will have a reimbursable benefit, Dr. Richeson said.

The new maintenance process centers around the creation of the CDBP Code Advisory Committee. Work on the next version of the CDT Code, effective Jan. 1, 2013, continues on schedule. Changes previously accepted by the CRC during its two meetings in 2011 will be included in the next version, as well as additional changes arising from CDBP consideration of requests submitted after the last CRC meeting in August.

CDBP's action on requests in the queue will be the final step in the council's new CDT Code maintenance process. During its December meeting, the ADA Board of Trustees approved the advisory committee's formation. Invitations to participate on the CAC have been sent to organizations involved in prior discussion of changes to the CDT Code, such as third-party payer and dental specialty organizations, as well as other sectors of the dental community. 

CAC comment will be considered by the council when it determines whether to accept or decline a requested change. The CAC's initial composition has five current or past council members, one of whom will serve as the chair, plus one representative from each of the nine recognized dental specialty organizations, one representative from the Academy of General Dentistry, one representative from each of the five payer organizations formerly on the CRC, including the Centers for Medicare and Medicaid Services and one representative from the American Dental Education Association.

CAC composition may change over time. The council is aware that evolving technology and regulatory mandates can prompt the need for advice and comment from additional sectors of the dental community. All CAC meetings are open to any interested party, including the public, other dental organizations or suppliers, and payer entities who may not be directly represented on the advisory committee.

CDBP considered how best to improve the code maintenance process, being particularly cognizant to provide for multiple avenues for comment during the decision process, Dr. Richeson said. The expansive opportunity for comment at the CAC meeting is not the only time when comment can be made. After the Subcommittee on the Code makes preliminary recommendations, those recommendations will go out for comment. The council will consider the subcommittee's recommendations and the comments on those recommendations when making final decisions. Code change submitters who have had their submissions declined will have an opportunity to appeal based on new information, if available.

About 140 change requests are in the queue for comment by the CAC and subsequent action by CDBP. This includes requests that were previously declined by a 6-6 vote, from all submitters. This is indicative of the care the council took to ensure fairness in the process to all.

The former CRC process included the availability of an appeal process for 6-6 votes. Since the CRC process no longer exists, submitters of code change requests that failed due to a 6-6 vote would have been disenfranchised of their right to appeal. Therefore, those requests will be given the full, fair and open treatment of the CAC process.

This opportunity is being provided equally to requests submitted by providers and payers. Requests that were previously passed by the CRC during the current revision cycle will not be reviewed.

The council will consider the following when decisions are made to accept a change request:

  • Advice and comment from the CAC;
  • Recommendations to accept or decline from the CDBP Subcommittee on the Code;
  • Comment on the recommendations of the subcommittee;
  • Change request evaluation guidelines adopted by the ADA Board of Trustees and posted on ADA.org.

The guidelines include:

  • Code change request evaluation should be based on the need for documenting procedures based upon the patient's dental needs and not on services covered by any applicable dental benefit plan;
  • Procedures that are being provided by dentists to patients should have a code available for documentation;
  • Procedure code nomenclatures and descriptors should be clear and unambiguous;
  • Nomenclatures and descriptors address the manner in which the procedure is delivered, and should not include references to time intervals when the procedure may be reported, or limitations on reporting with other procedures;
  • The alleged potential for abuse or fraudulent use of a code should not be considered as an evaluation guideline;
  • Community standards of care should not limit consideration of other evaluation criteria.

Final decisions on the remaining change requests will be made during the council's April  meeting and submitters will have an opportunity to appeal. All accepted changes will be in the next version of the CDT Code. This process will be repeated each year to enable the CDT Code to be responsive to the needs of the profession.

Information about the CDBP CDT Code maintenance process, featuring a simplified change request submission, will be posted on ADA.org to replace out-of-date material. There will be periodic additions and updates to the material posted at Code on Dental Procedures and Nomenclature (CDT).

Questions and requests for additional information may be directed to CDBP staff via email at dentalcode@ada.org or via telephone to the ADA toll free.