Questions and Answers
(Q&A)
The following information is offered by the Council on Dental Benefit Programs (CDBP) and is in addition to that published in the CDT manual. These Q&A are provided to assist a dentist and practice staff in determining which procedure code is most appropriate to describe the service provided, and better understand the claim form completion and adjudication processes.
Please note that; 1) this information is not part of the Code on Dental Procedures and Nomenclature (Code), and 2) dental benefit plan coverage limitations and exclusions, and where applicable the provisions of a participating provider agreement, affect third-party payer claim adjudication..
Coding
1. What is an operculectomy, and how would it be coded?
In dentistry, an operculum is a small flap of inflamed tissue surrounding the back molars and “…ectomy” is a surgical suffix referring to the removal of something. Therefore, an operculectomy is the surgical removal of a flap of tissue surrounding a partially erupted or impacted tooth.
Coding:
D7971 excision of pericoronal gingiva
Surgical removal of inflammatory or hypertrophied tissues surrounding partially erupted/impacted teeth.
2. What is the code for using a laser?
A laser is an instrument and can be used in many dental applications. The dental procedure codes are procedure based rather than instrument based. For example, if a gingivectomy on tooth 8 was performed using a scalpel or a laser, the procedure code would be the same.
Coding:
D4211 gingivectomy or gingivoplasty—one to three teeth or bounded teeth spaces per quadrant.
3. What is a dry socket and how would treatment be coded?
A dry socket is localized inflammation of the tooth socket following extraction due to infection, loss of the blood clot; osteitis.
Coding:
D9930 treatment of complications (post surgical)—unusual circumstances, by report
For example, treatment of a dry socket following extraction or removal of bony sequestrum.
4. What is a fibroma and how would removal be reported?
A fibroma is a benign tumor composed of fibrous or connective tissue. They can grow in all organs.
Coding:
D7410 excision of benign lesion up to 1.25 cm
D7411 excision of benign lesion greater than 1.25 cm
Claim Form
(No Q&A at this time. Please check next month for updates.)
Adjudication
Sometimes how a payer adjudicates a claim appears inconsistent with the ADA’s message—“code for what you do.”
For example, the dentist reports D2330 resin-based composite—one surface, posterior on tooth #18. But, when the benefit contract makes an allowance equivalent to an amalgam restoration on posterior teeth, the payer may adjudicate the claim using D2140 amalgam—one surface, primary or permanent. Should this happen 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.
Contact Information
Telephone: ADA Members, please use the toll-free number on the back of your membership card; Direct dial, 312-440-2500
E-mail: dentalcode@ada.org |
