Most Frequently Misused Codes in 2018

We are more than half way through 2018 yet there are some offices that are using a coding reference that is not up to date with the current 2018 ADA code set. Attempting to code and bill correctly from an old reference can be costly and ultimately dangerous.

The mantra of a well-trained valuable team member responsible for doing the coding and billing should be to use the best code available to describe the service provided to maximize legitimate reimbursement while reducing the risk associated with improper coding. So, in the current 2018 ADA code set, what are some of the most commonly misused codes?

One of the codes that tends to be overlooked and seldom used is the D0180, COMPREHENSIVE PERIODONTAL EVALUATION – NEW OR ESTABLISHED PATIENT

This 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.

This code describes an evaluation (initial or periodic) where, in addition to the other components of an initial or periodic evaluation, a full mouth charting must be done as a part of the comprehensive periodontal evaluation. The D0150 (Comprehensive oral evaluation – new or established patient) and the D0120 (periodic oral evaluation – established patient) indicate that a periodontal evaluation is provided as indicated or that the evaluation may include.

The full mouth probing and charting must be done as a part of D0180, the comprehensive periodontal evaluation and the patient must have signs and symptoms of periodontal disease or are at higher risk. Coincidentally, this code is generally reimbursed at a higher rate rather than the D0120 and less than the D015. It should be stressed that the reimbursement should not affect which code is chosen to describe the service. The code that provides the best description of the service provided should be selected and submitted to the carrier for reimbursement.

There also is a tendency to misuse some of the gingival/periodontal codes: D4355/D4341/D4342/D4346/D4910/D1110. The services associated with treating gingivitis, periodontal disease and the periodic maintenance of the gingival tissues can often be miscoded. When determining the best code to describe treatment and maintenance of the patient’s gingival conditions, that treatment and coding/billing of those services should be driven by the periodontal diagnosis. Note: when the D4355 the descriptor and nomenclature was modified in the 2018 code set, it is clear that an evaluation cannot be completed on the day the debridement is completed. The evaluation (D0150, D0160, D0180 would be completed at a subsequent visit.

D4355 states: FULL MOUTH DEBRIDEMENT TO ENABLE A COMPREHENSIVE ORAL EVALUATION AND DIAGNOSIS ON A SUBSEQUENT VISIT. Full mouth debridement involves the preliminary removal of plaque and calculus that interferes with the ability of the dentist to perform a comprehensive oral evaluation. This is not to be completed on the same day as D0150D0160, or D0180.

When determining the periodontal diagnosis, the team should be calibrated. That is, the dentist and hygienist should agree on the definition of healthy gingival tissue, gingivitis and what constitutes periodontal disease and the team should understand how to code the treatment of that condition.

The hygienist generally collects the objective information derived from their review of the patient’s condition and the hygienist can suggest to the doctor a diagnosis based on those findings. Once a diagnosis is determined, the doctor can determine the proper treatment and coding of that treatment. Note that the hygienist may do the periodontal charting of existing conditions but it’s the dentist that must determine the need for radiographs and determine the patient’s periodontal diagnosis (except in Oregon and Colorado where hygienist my diagnose with the proper credentialing).

When determining the patient’s periodontal diagnosis, there are three variables that are used to derive the periodontal/gingival diagnosis.

Those three variables are: Is the condition:

  • Mild/Moderate/severe
  • Generalized/Localized
  • Chronic/Acute

Using the three sets of variables, an example of a gingival condition might be “moderate generalized chronic gingivitis” or the diagnosis could be “severe localized chronic periodontal disease” to name just a couple of examples.

If the patient were diagnosed with periodontal disease, the treatment of the disease or maintenance of the periodontal condition would be described using a periodontal code. The initial treatment of the periodontal disease could be scaling, and root planing or periodontal surgery based on the patient’s needs. The coding would be determined based on the service provided to treat the patient’s diagnosed condition. D4910 is the best code to describe the periodontal maintenance of the patient’s diagnosed periodontal condition after SRP or Periodontal surgery. Bone and/or attachment loss are the hallmarks of periodontal disease.

A patient with gingivitis (inflammation without bone loss) could the treated using the D4346 if they are diagnosed with moderate or severe generalized inflammation or D1110 (prophylaxis) for mild generalized or localized inflammation.

Extractions are another area of confusion in some dental practices. Extractions D7140 and D7210 are frequently miscoded. Many practices are not using the correct extraction code to describe extractions. One of two things must occur and be documented in the clinical records to elevate a simple extraction (D7140) to a surgical extraction D7210. D7210 describes the EXTRACTION of an ERUPTED TOOTH REQUIRING REMOVAL OF BONE AND/OR SECTIONING OF TOOTH, AND INCLUDING ELEVATION OF MUCOPERIOSTEAL FLAP, IF INDICATED.

This surgical extraction service includes related cutting of gingiva and bone, removal of tooth structure, minor smoothing of socket bone and closure.

As the descriptor states, the surgical extraction should include the removal of bone and/or section of the tooth to report the extraction as surgical, reporting D7210. If bone is not removed nor the tooth requires sectioning to remove, the extraction is considered simple even if a flap is used and sutures placed.

Implant single crowns/bridge retainer’s codes: There can be confusion about what type of implant, crown or retainer crown code to use when restoring implants. There are two basic types of implant crowns and retainers. One type of crown/retainer crown is fabricated to be supported by an abutment, and the other type of implant crown/retainer is attached directly to the implant, generally by a screw, and the screw access opening is sealed with restorative material. Once the type of attachment is determined, choose the code in those sets of codes that specify the materials used to fabricate the crown/retainer.

Radiographs: Radiographs should be taken based on the needs of the patient, not just when the insurance will pay for them. A great reference to help in making radiograph decisions is:  https://www.ada.org/~/media/ADA/Member%20Center/FIles/Dental_Radiographic_Examinations_2012.pdf

Be aware that for the radiographic image to be billable, they need to be diagnostic (clinically acceptable) and the doctor must read them. Do not bill for a non-diagnostic film and documentation should support the fact that the doctor read the radiographs.

These are just a few examples of commonly misunderstood and misused codes. Understanding the current codes and how they are to be utilized may eliminate errors. Errors can be costly and can put the practice at risk should there be an audit done that identifies errors of these types.  The goal of every practice should be to maximize legitimate reimbursement and to eliminate error.

Dr. Roy Shelburne opened a private general practice in Pennington Gap, Virginia, in 1981. In March 2008, he surrendered his dental license after being convicted of healthcare fraud and spent 19 months in Federal Prison and 2 months in a halfway house. Dr. Shelburne is a nationally known speaker/writer/and consultant who openly shares his mistakes, what he learned as a result, and how to avoid those career ending errors.