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Oral Health Coding Fact Sheet

Updated 1/1/2016
Download the full PDF version.

CPT Codes:
Current Procedural Terminology (CPT) codes are developed and maintained by the American Medical Association. The codes consist of 5 numbers (00100 - 99999). These codes are developed for physicians and other health care professionals to report medical procedures to insurance carriers for payment.

CDT Codes: Code on Dental Procedures and Nomenclature (CDT) codes are developed and maintained by the American Dental Association. These codes provide a way to accurately record and report dental treatment. The codes have a consistent format (Letter D followed by 4 numbers) and are at the appropriate level of specificity to adequately encompass commonly accepted dental procedures. These needs are supported by the CDT codes.
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Prophylaxis and Fluoride Varnish
99188​Application of topical fluoride varnish by a physician or other qualified health care professional
  • This code was approved to begin January 1, 2015.  It only includes varnish application, not risk assessment, education, or referral to a dentist.
  • The USPSTF recommended this for children up to 6 years of age.  Therefore Code 99188 must be covered by commercial insurance by May 2015 for children up to age 6.  Check with your insurers for specifics.
  • No RVU have been set by CMS because Medicare does not cover dental related services
  • The Section on Oral Health tracks payment for services.
D1206Topical application of fluoride varnish
D1208Topical application of fluoride
99429Unlisted preventive medicine service   
99499Unlisted evaluation and management service
 
Other Preventive Oral Health Services
D1310Nutritional counseling for the control of dental disease
D1330Oral hygiene instruction
 
Clinical Oral Evaluation
D0140Limited oral evaluation, problem focused
D0145Oral evaluation for patient under 3 years of age and counseling with primary caregiver
 
Oral Procedures
D7140Extraction, erupted tooth or exposed root (elevation and/or forceps removal)
Alternate coding: CPT code 41899 Unlisted Procedure, dentoalveolar structures. While use of a more specific code (ie, D7140) is preferable to a nonspecific code (ie, 41899), reporting the CPT code may increase a pediatrician’s likelihood of getting paid. As an unlisted service, chart notes may need to accompany the claim.
 
Modifiers
For those carriers (particularly State Medicaid plans under EPSDT), that cover oral health care, some will require a modifier (See “Private Payers and Medicaid” below)

SC – Medically necessary service or supply
EP – Services provided as part of Medicaid early periodic screening diagnosis and treatment program (EPSDT)
U5 – Medicaid Level of Care 5, as defined by each sate

Other (Referral Codes)

YD Dental Referral
  • This referral code is used in the state of Pennsylvania for EPSDT services and may be used by other payers
NOTE: The diagnosis codes below are used to deal with occasions when circumstances other than a disease or injury are recorded as “diagnoses” or “problems.” Some carriers may request supporting documentation for the reporting of V codes. These codes may also be reported in addition to the primary ICD-9-CM code to list any contributing factors or those factors that influence the person’s health status but is not in itself a current illness or injury.

While they may be the appropriate code(s) to report when performing oral health screening, payment can be inconsistent, especially when linked to a procedure code for something other than well child care
ICD-10-CM Codes
  • For use on or after October 1, 2015
E08.630 ​Diabetes Due to Underlying Condition with Periodontal Disease
E09.630 ​Drug/chem Diabetes Mellitus w/Periodontal Disease
E10.630​Type 1 Diabetes Mellitus with Periodontal Disease
E11.630​Type 2 Diabetes Mellitus with Periodontal Disease
K00.3​Mottled teeth
K00.81​Newborn Affected by Periodontal Disease in Mother
K02.3​Arrested dental caries
K02.51​Dental caries on pit and fissure surface limited to enamel
K02.52​Dental caries on pit and fissure surface penetrating into dentin
K02.53​Dental caries on pit and fissure surface penetrating into pulp
K02.61​Dental caries on smooth surface limited to enamel
K02.62​Dental caries on smooth surface penetrating into dentin
K02.63​Dental caries on smooth surface penetrating into pulp
K02.9​Dental caries, unspecified
K05.00 ​Acute gingivitis, plaque induced (Acute gingivitis NOS)
K05.01​Acute gingivitis, non-plaque induced
K05.10​Chronic gingivitis, plaque induced (Gingivitis NOS)
K05.11​Chronic gingivitis, non-plaque induced
K05.5​Other Periodontal Diseases
K05.6​Periodontal Disease, Unspecified
K06.0​Gingival Recession   
K06.1​Gingival Enlargement
K06.2​Gingival & Edentulous Alveolar Ridge Lesions Associated with Trauma
K08.121​Complete Loss of Teeth Due to Periodontal Diseases, Class 1
K08.122​Complete Loss of Teeth Due to Periodontal Diseases, Class II
K08.123​Complete Loss of Teeth Due to Periodontal Disease, Class III
K08.124​Complete Loss of Teeth Due to Periodontal Diseases, Class IV
K08.129​Complete Loss of Teeth Due to Periodontal Disease, Unspecified Class
K08.421​Partial Loss of Teeth Due to Periodontal Diseases, Class I
K08.422​Partial Loss of Teeth Due to Periodontal Diseases, Class II
K08.423​Partial Loss of Teeth Due to Periodontal Diseases, Class III
​K08.424​Partial Loss of Teeth Due to Periodontal Diseases, Class IV
K08.8​Other specified disorders of teeth and supporting structures
R19.6​Halitosis
S02.5XX-​Fracture of tooth (traumatic)
S03.2XX-​Dislocation of tooth
  • A 7th character is required for both S02 and S03 to show the encounter.  7th character “A” would show that the encounter is for initial or active treatment
  • Also include other codes that relate to the payer how the injury happened, including location and activity. Some states require the reporting of this information.
Z00.121​Encounter for routine child health examination with abnormal findings (Use additional code to identify abnormal findings, such as dental caries)
Z00.129​Encounter for routine child health examination without abnormal findings
Z13.84​Encounter for screening for dental disorders
Z41.8​Encounter for other procedures for purposes other than remedying health state (topical fluoride application)
Z71.89​Other Specified Counseling
Z72.4​Inappropriate diet and eating habits
Z92.89​Personal history of other medical treatment

Private Payers and Medicaid

Most private/commercial payers must pay for 99188 under the health or medical plans for children up to age 6 by May, 2015 because the US Preventive Services Task Force recommended it as a Level B recommendation.  They are not mandated to cover older children.   The primary reasons why medical health plans do not cover the fluoride varnish, risk assessment, education, and referral to a dentist  are that the health plan does not include dental services, or if there is limited coverage for certain dental services, the provider network is limited to dentists or oral surgeons. Since most carriers’ claims systems do not recognize the dental service codes (D codes) on their medical claims platforms, CPT code 99188 was developed in 2015. Starting in 2014, the Affordable Care Act requires that individual and small-group health plans sold both on the state-based health insurance exchanges and outside them on the private market cover pediatric dental services performed by dental professionals. However, health plans that have grandfathered status under the law, or employers whose plans are covered under ERISA by Third Party Administrators, are not required to offer this coverage.
 
At the following link you can find a chart about Medicaid reimbursement and which codes to use by state http://www2.aap.org/oralhealth/docs/OHReimbursementChart.pdf.  However, please check with your individual state as their procedures change frequently without uniformity!

FAQ

Q. When was the new CPT code (99188) effective?
A. The CPT Editorial Panel approved the new CPT code 99188 for implementation on January 1, 2015.

Q. May I still bill the CDT code for topical fluoride application to my Medicaid plan or must I use the new CPT code?
A. If your Medicaid plan still requires and will pay on the CDT codes, you should continue to report the CDT codes as defined by your Medicaid plan. This will vary from state to state.

Q. Our practice was happy to see the new CPT code; however, what does it mean “by a physician or other qualified health care professional”?
A. In order to obtain approval by the CPT Editorial Panel, we had to include this language as part of the code descriptor. Inclusion of this language does limit who may perform and report the service. The CPT definition “other qualified health care professionals” excludes clinical staff such as RNs and LPNs. Basically, an “other qualified health care professional” is one who can independently practice and bill under her own name. In practice, this means that CPT requires a physician or other qualified health care professional perform the topical fluoride application.  While state scope of practice and Medicaid qualifications may allow clinical staff (eg, RN) to perform this service, CPT guidelines do not allow the reporting of code 99188 in those instances.  However, if you are able to work with your payers and get it in writing that they will allow clinical staff to perform the service based on state scope of practice, and report incident to the supervising provider, then you would be able to use the code. Note that the CDT codes do not have this restriction.  Also there is a caveat in the “CPT Changes” manual that alludes to the application of topical fluoride varnish to those patients with “high risk” for dental caries.

Q. What is the value for this new code?
A. When the AAP brought the code to the valuation committee, our recommended relative value units (RVUs) were accepted by the committee and submitted to CMS for consideration on the Medicare physician fee schedule. However, CMS decided not to publish the recommended RVUs.  Instead, the code was published with zero RVUs. While this is the Medicare fee schedule, many private payers follow this. The AAP is currently advocating for CMS to publish the recommended RVUs for code 99188.

Q. Should we advocate for coverage by payers and if so, for how much?
A. Yes. The AAP encourages working with your AAP State Chapter. Because there are no RVUs published, if your Medicaid sets a payment rate for this service, you should advocate for that rate at minimum. However, it will be important to determine with your payers if they will require physicians or other qualified health care professionals to perform the service, or if they will base the requirements on state scope of practice or Medicaid qualifications.

Q. If this new CPT code (99188) is to be used for “high risk caries” – how do you identify that? Is a formal screen required?
A. At this moment in time there is not a validated risk assessment tool for dental caries and the application for the CPT code was submitted prior to the publication of the new USPSTF guidelines so it contains information regarding risk. Even so, the state of "high risk" is at the discretion of the examining physician. The AAP does have a risk assessment tool (http://www2.aap.org/oralhealth/riskassessmenttool.html) that can be used as a guide, but ultimately it is deferred to the clinician's judgment and may be provided to all children under the age of six as a preventive service if that is the approach the clinician wishes to take. The USPSTF recommendations
(http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/dental-caries-in-children-from-birth-through-age-5-years-screening) and more recent AAP policy (http://pediatrics.aappublications.org/content/134/3/626.abstract ) certainly back this approach should someone need information to present to a payer.
   
So to answer your questions, yes, we would agree that a child who is without a dental home is high risk and should have varnish applied in the medical home, and no, I don't think there is something more discernible that can only be used by dental professionals to assess risk and therefore would leave a pediatrician without the opportunity for payment. There are no validated tools being used in dentistry currently either.
 
While this may seem a little confusing, this is an evolving area and we are doing our best to keep up!
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