Why are diagnostic codes included in claims filed for dental benefits?
In dental claim filing, CDT codes are used to inform the dental payer of what procedures were performed. Diagnostic codes will identify why that procedure was performed, by informing the payer of the associated disease, illness, symptom or disorder.
What is ICD-10-CM?
ICD-10-CM is the 10th revision to International Classification of Diseases (ICD), Clinical Modification (CM). Its primary purpose is epidemiological tracking of illness and injury.
ICD-10-CM is the Health Insurance Portability & Accountability Act of 1996 (HIPAA) standard diagnostic code set for use in electronic transactions such as electronic claims.
See more details about the history of ICD at the ADA ICD 10 home page
How do I select the appropriate diagnostic codes?
Where can I find a complete list of ICD-10-CM?
Most ICD codes that pertain to dental procedures are found in Chapter 11, Diseases of the Digestive System (K00-K95). Other diseases relevant to dentistry may be found in other chapters.
The ICD10 Data site can be used to look up particular codes or families of codes, while the complete ICD-10-CM code set is also available for download free of cost at the CDC site. Scroll down the page and select the ICD10CM/2015 folder at the FY 2015 release of ICD-10-CM:
Our State Medicaid Program requires my dental practice to currently report ICD codes in dental claims. Why do we need to currently report ICD-9-CM and ICD-10-CM on October 1, 2015?
Through ICD reporting, it is hoped that there will be a benefit to providers and patients over time by improving the tracking of treatment and associated ICD codes.
State Medicaid Programs that require ICD reporting would like to capture clinical data to support public health activities, to support development of evidence-based benefits plans, and to support funding efforts. ICD reporting is also required to facilitate payment for services related to the oral-systemic connection and coverage for additional dental services for certain medical conditions.
What is the implementation date for ICD-10-CM?
The implementation date for ICD-10-CM is October 1, 2015.
The HIPAA rules require covered entities to continue to use ICD-9-CM through September 30, 2015. However, not all dentists need to report ICD-10-CM in dental claims. As of late September 2015, only one state Medicaid programs, Nevada, requires all dentists to report ICD in Medicaid dental claims for any dental procedure.
Which State Medicaid Programs have current diagnostic code reporting requirements
Arizona, Iowa, Maine, Michigan, and Nevada have at least some diagnostic code reporting requirements.
Only Nevada Medicaid has across the board requirements for diagnosis code reporting on all dental claims. Arizona, Iowa, Maine, and Michigan have requirements for reporting of certain diagnoses.
Other States may follow their examples. If your practice participates with Medicaid in one of these states, refer to your state Medicaid program’s dental claim preparation instructions or contact your state Medicaid program directly for details.
How do I know whether a commercial dental plan or a State Medicaid Program requires a diagnosis code to adjudicate a claim for a given procedure or group of procedures?
You must check with your individual patients' commercial dental plans or your state Medicaid program. You should also refer to their claim preparation and submission instructions.
I have Medicaid patients and my State Medicaid Program does not require me to report ICD codes in dental claims. What should I do?
Complete your claims as usual, without using the diagnostic codes. Remember that state Medicaid program payers may elect to require diagnostic codes in the future, so be sure to stay current with your state Medicaid requirements. If you have Medicaid patients and your state Medicaid does not require you to report ICD codes in dental claims, you should make sure to check their website frequently to ensure that nothing has changed.
How can I find out my State Medicaid organization’s requirements?
I occasionally submit claims to a patient’s medical benefit plan. Will my practice need to transition to ICD-10-CM?
Yes. Many dentists and dental specialists will be familiar with reporting diagnoses on medical professional claims using ICD-9-CM. They will continue to report diagnoses on all medical professional claims but will have to use ICD-10-CM codes for service dates on and after October 1, 2015.
Our State Medicaid Program requires my dental practice to currently report ICD-9-CM in dental claims. What should I do and where can I find more information about completing the ADA 2012 Dental Claim?
If your State Medicaid Program requires you to report ICD codes in dental claims, you must report an appropriate ICD diagnostic code for dental conditions along with the applicable CDT code for the service performed.
The meaning of “appropriate” in relation to diagnostic codes may vary: it must be a valid and current code AND it should be relevant and specific enough to provide a rationale for the service reported.
The ADA 2012 Dental Claim Form can accommodate ICD diagnostic codes. See these claim form completion instructions
Also, please check your state Medicaid program's website, as they may have additional instructions available.
If my State Medicaid Program or Commercial Insurance requires me to report ICD codes in dental claims, do I need to upgrade my Practice Management System?
You may need to upgrade your system but make sure you check with your system vendor first. Contact your Practice Management System vendor if you require technical assistance with including ICD codes on a claim form.
My state Medicaid Program requires ICD reporting in dental claims. When ICD-10-CM codes replace ICD-9-CM codes on October 1, 2015, will it impact how I report Current Dental Terminology (CDT) codes?
No, there will be no impact on CDT codes. When ICD codes are reported on a dental claim, they are reported in addition to the CDT codes for services provided.
When ICD-10-CM codes replace ICD-9-CM codes on October 1, 2015, it will not impact how you report CDT. While ICD-10-CM codes have expanded detail for some oral health conditions, you should continue to use the most current version of CDT when you report CDT codes in your dental claims.
My practice is filing paper claims and my State Medicaid Program requires ICD reporting. Am I required to transition to ICD-10 on October 1, 2015?
Yes. On or after October 1, 2015, all claims reported (paper and electronic) must use the current code set, ICD-10-CM, if required by the payer.
All dental providers should check with their State Medicaid Program if ICD reporting on dental claims is required.
My billing department notified me about some dental plans allowing additional benefits for certain medical conditions. Are the ICD codes required?
Some dental plans allow additional benefits for certain medical conditions. When this happens, an ICD code is required when the diagnosis may have an impact on the adjudication of the claim, particularly in cases where specific dental procedures may minimize the risks associated with the connection between the patient’s oral and systemic health conditions.
You should make sure to check with your dental plans to ensure that they allow additional benefits for certain medical conditions e.g. diabetes etc.
I do not have Medicaid patients. Do I need to report ICD codes in dental claims?
Some commercial carriers may require a diagnosis code for dental services connected to patients systemic conditions. For example a diabetic patient may be eligible for an extra cleaning.
You should make sure to check payers’ websites frequently to ensure that nothing has changed.
Will commercial dental plans require diagnosis codes on all dental claims in the future?
That is unknown at this time. For the moment, most dental plans have not announced any intentions to require the use of diagnostic coding for routine dental claims. There are some benefit plans that ask for them to provide additional dental benefits for particular systemic diseases, such as diabetes or pregnancy.
What is a Diagnosis Code?
A diagnosis code is a unique, alphanumeric string of characters that represents a disorder or disease concept. Diagnostic coding is the translation of written descriptions of diseases, illnesses and injuries into standardized codes. These codes are used to group and identify diseases, disorders and symptoms.
The diagnosis code set currently used in the United States is the International Classification of Disease, 9th Edition Clinical Modification (ICD-9-CM).
ICD-10-CM will be implemented on October 1, 2015.