Key Words

This procedure involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. It is indicated for patients with periodontal disease and is therapeutic, not prophylactic, in nature. Root planing is the definitive procedure designed for the removal of cementum and dentin that is rough, and/or permeated by calculus or contaminated with toxins or microorganisms. Some soft tissue removal occurs. This procedure may be used as a definitive treatment in some stages of periodontal disease and/ or as part of pre-surgical procedures in others.

D4342 Periodontal scaling and root planing – one to three teeth per quadrant

D2950 Core buildup, including any pins when required Refers to building up of coronal structures when there is insufficient retention for a separate extracoronal restorative procedure. A core buildup is not a filler to eliminate any undercut, box form, or concave irregularity in a preparation.

With D2950, core buildup, it is important to review the descriptor to determine the key words for this code. This descriptor clearly establishes that a core buildup is medically necessary when there is insufficient retention for the indirect restoration. The clinical record and the narrative and/or supporting documentation should establish that, without the core buildup, the existing tooth structure would not be sufficient to provide adequate retention of the extracoronal restoration. Supportive radiographic images and photographs of the preparation also help document the lack of retention available without a core buildup.

In addition to a core buildup being required for retention of the crown, there are two other significant indicators that a core buildup is required. First, be sure to note the amount of tooth remaining after preparation. At least 50 percent of the tooth should be missing in order to qualify for reimbursement. Second, a history of endodontic treatment can impact the reimbursement of a core buildup. If the tooth has received endodontic treatment, be sure to document that fact by sending a radiographic image of the tooth showing the completed endodontic therapy.

Cracked Tooth Syndrome (CTS)

In most instances, the treatment for true cracked tooth syndrome is a full coverage indirect restoration (crown). Many plans do not consider a full coverage indirect restoration for an asymptomatic tooth with visual “cracks” to be medically necessary. However, if there is some type of discomfort associated with the crack, benefits may be available. Thus, the key word associated with a cracked tooth that helps to establish medical necessity and gain reimbursement is pain.

Cracked teeth show a variety of symptoms, including erratic pain when chewing, possibly with release of biting pressure or when the tooth is exposed to extreme temperatures. In many cases, the pain may come and go, or be episodic. If there is pain associated with the tooth, note the painful symptoms in the clinical record and on the claim. Also indicate if the patient presented for a previous appointment to relieve the pain (e.g., by adjusting the bite) and that the attempt was ineffective and did not alleviate the pain.

The presence of pain improves the chances of obtaining reimbursement for the crown. In many cases, a visual internal crack without pain is not enough to establish medical necessity. It is essential to document how the diagnosis of cracked tooth syndrome was determined (i.e., bite stick, Tooth Slooth®, transillumination, orthodontic band placement, etc.).

Palliative Treatment

D9110 Palliative (emergency) treatment of dental pain – minor procedure This is typically reported on a “per visit” basis for emergency treatment of dental pain.

Justification (medical necessity) for a palliative treatment is that the patient presents with pain, a treatment is provided (not just an evaluation and a prescription for medication), and the treatment provided is minor (not a definitive treatment).

The clinical record and supporting claim documentation should include the key word, establishing that the patient presented with pain at the emergency visit. Furthermore, the supporting documentation should specifically describe the minor treatment provided to relieve the patient’s painful symptoms. Note that palliative treatment is a stand-alone treatment and is seldom considered for reimbursement when provided in conjunction with any other definitive procedure on the same service date.

Comprehensive Periodontal Evaluation

D0180 Comprehensive periodontal evaluation – new or established patientthis procedure is indicated for patients showing signs or symptoms of periodontal disease and for patients with risk factors such as smoking or diabetes. It includes evaluation of periodontal conditions, probing and charting, evaluation and recording of the patient’s dental and medical history and general health assessment. It may include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, occlusal relationships and oral cancer evaluation.

The descriptor associated with the comprehensive periodontal evaluation (D0180) helps establish the key words required. The code states, “This procedure is indicated for patients showing signs or symptoms of periodontal disease and for patients with risk factors such as smoking or diabetes.” Documenting the existence of periodontal risk factors can help to establish medical necessity for a comprehensive periodontal evaluation.

The clinical record and the supportive narrative should note the periodontal diagnosis (e.g., chronic generalized severe periodontitis) and/or list the risk factors for periodontal disease that are present (e.g., smoking, diabetes, etc.).

Consultation

D9310 Consultation – diagnostic service provided by dentist or physician other than requesting dentist or physician  A patient encounter with a practitioner whose opinion or advice regarding evaluation and/or management of a specific problem; may be requested by another practitioner or appropriate source. The consultation includes an oral evaluation. The consulted practitioner may initiate diagnostic and/ or therapeutic services.

The key words for a consultation revolve around who referred the patient and why the referral was made. Be sure that the clinical record and the claim answers the key questions:

»» Who referred the patient (the other practitioner or appropriate source)?

»» Why was the patient referred?

Reimbursement for a consultation is variable and may be higher (overall) than a standard new patient evaluation.

Fluoride Varnish (for adults)

D1206 Topical application of fluoride varnish

Note: The patient’s plan document will clearly state whether or not benefits are available for fluoride varnish provided to an adult patient. If this is not a covered treatment, reimbursement will not be provided. If benefits are available, here are some important tips to properly document the procedure. The fluoride varnish code (D1206) was modified, and the Code Maintenance Committee (CMC) decided to drop the moderate or greater caries risk requirement. However, some payers continue to mandate the adult patient have moderate to high caries risk for the reimbursement of fluoride varnish. As a result, a caries risk assessment should be performed, documented in the clinical chart, and properly reported on the claim form (typically at “zero” fee, as this is included in the global fee for the evaluation). A finding of moderate or high caries risk could increase the potential for reimbursement.

Caries risk assessments, D0602 (moderate) or D0603 (severe), should be reported on the claim to help establish medical necessity. An appropriate narrative might state:

“Caries risk assessment placed the adult patient at high risk for dental caries.”

Many payers have specific limitations for the reimbursement of treatments of specific conditions. It is important that these conditions are noted and that the information is conveyed to the payer. Providing the documentation required to support the medical necessity of treatment is essential. Including the key words will help establish medical necessity and, thereby, improve the likelihood of timely reimbursement and avoid requests for additional information or denials of the claim.