A Brief History

The CDT Code was first published in 1969 as the “Uniform Code on Dental Procedures and Nomenclature” in the Journal of the American Dental Association. It originally consisted of numbers and a brief name, or nomenclature. Since 1990, the CDT Code has been published in the American Dental Association’s dental reference manual titled Current Dental Terminology (CDT). The CDT Code version published in CDT-1 (1990) was marked by the addition of descriptors (a written narrative that provides further definition and the intended use of a dental procedure code) for most of the procedure codes.

The American Dental Association is the copyright owner and publisher of the CDT Code. New versions are published every year and become effective January 1st.

Federal regulations and legislation arising from the Health Insurance Portability and Accountability Act of 1996 (HIPAA) require all payers to accept HIPAA standard electronic dental claim. One data element on the electronic dental claim is the dental procedure code, which must be from the CDT Code — specifically the version that is effective on the date of service.

Purpose

The CDT Code supports uniform, consistent, and accurate documentation of services delivered. This information is used in several ways:

• To provide for the efficient processing of dental claims

• To populate an electronic health record

• To record services to be delivered in a treatment plan

Note: Treatment plans must be developed according to professional standards, not according to provisions of the dental benefit contract. Always keep in mind that the existence of a procedure code does not guarantee that the procedure is a covered service.

Categories of Service

The CDT Code is organized into twelve categories of service, each with its own series of five-digit alphanumeric codes. These categories:

• Exist solely as a means to organize the CDT Code

• Reflect dental services that are considered similar in purpose

• Contain CDT Codes that are available to document services delivered by anyone acting within the scope of their state law (for example, a dentist in general practice uses D7140 that is found in the oral and maxillofacial surgery category to document an extraction).

#	Name	Code Range	Description in commonly used terms*
I.	Diagnostic	D0100-D0999	Examinations, X-rays, pathology lab procedures
II.	Preventive	D1000-D1999	Cleanings (prophy), fluoride, sealants
III.	Restorative	D2000-D2999	Fillings, crowns and other related procedures
IV.	Endodontics	D3000-D3999	Root canals
V.	Periodontics	D4000-D4999	Surgical and non-surgical treatments of the gums and tooth supporting bone
VI.	Prosthodontics – removable	D5000-D5899	Dentures – partials and “flippers”
VII.	Maxillofacial Prosthetics	D5900-D5999	Facial, ocular and various other prostheses.
VIII.	Implant Services	D6000-D6199	Implants and implant restorations
IX.	Prosthodontics – fixed	D6200-D6999	Cemented bridges
X.	Oral & Maxillofacial Surgery	D7000-D7999	Extractions, surgical procedures, biopsies, treatment of fractures and injuries
XI.	Surgery Orthodontics	D8000-D8999	Braces
XII.	Adjunctive General Services	D9000-D9999	Miscellaneous services including anesthesia, professional visits, therapeutic drugs, bleaching, occlusal adjustment

* The language used in the “Description” column has been simplified using common non-clinical terms. It is not technical terminology.

Subcategories

All CDT Code categories of service are subdivided into one or more subcategories to aid navigation through the code set. For example, subcategories in the Diagnostic category of service include:

• Clinical Oral Evaluations

• Diagnostic Imaging

• Tests and Examinations

Note: CDT Code entries are not always in numerical order within a category of service. As the CDT Code grows and evolves, there are times when there is no sequential number available for a new entry that is related to an existing code.

Components of a CDT Code Entry

Every dental procedure code within a category of service has at least the first two and sometimes all three of the following components:

Procedure Code – A five-character alphanumeric code beginning with the letter “D” that identifies a specific dental procedure. Each procedure code is printed in boldface type in the CDT manual and cannot be changed or abbreviated.

Nomenclature – The written, literal definition of a procedure code. Each code has a nomenclature that is printed in boldface type in the CDT manual. Nomenclature may be abbreviated only when printed on claim forms or other documents that are subject to space limitation. Any such abbreviation does not constitute a change to the nomenclature.

Descriptor – A written narrative that provides further definition and describes the intended use of a dental procedure code. A descriptor is not provided for every procedure code. Descriptors that apply to a series of procedure codes may precede that series of codes; otherwise a descriptor will follow the applicable procedure code and its nomenclature. When present, descriptors are printed in regular typeface in the CDT manual. Descriptors as published cannot be added, abbreviated or otherwise changed.

Descriptors are a very important component. Understanding the descriptor can help determine whether the procedure code accurately describes the service provided to a patient. This information can also help resolve questions about the accuracy of claim submissions.

Note: Your practice management software may not include entire CDT Code entries as some, due to space limitations, truncate nomenclatures and omit descriptors. With the current CDT Manual at hand you will have the complete entries for all CDT Codes, which will help you select the appropriate code to document and report the service delivered.

What If There is No Code Describing a Procedure?

The complete CDT Code entry, described above, published in the current CDT Manual is used to determine the procedure code for documenting and reporting a service provided to a patient. But, what if there is no CDT Code that, in the dentist’s opinion, is applicable to the service? The available and appropriate option is to use an “unspecified procedure, by report” code, also known as a “999” code. These codes (e.g., D2999 unspecified restorative procedure, by report) are in every category of service, and when used must include a supporting narrative that explains the service provided.

A third-party payer may request additional documentation of certain procedures regardless of the presence of the narrative. Note, too, that dental benefit plan coverage limitations and exclusions, and where applicable the provisions of a participating provider agreement, affect third-party payer claim adjudication and reimbursement.

Narratives for “By Report” Codes

There are two types of CDT Codes that require an explanatory narrative. The first and most readily known type are the “unspecified…procedure, by report” codes found in every category of service. Second are those codes in several categories that include “by report” in their nomenclatures – as seen in the following two examples.

D5862 precision attachment, by report

Each set of male and female components should be reported as one precision attachment. Describe the type of attachment used.

D6100 implant removal, by report

This procedure involves the surgical removal of an implant. Describe procedure.

When preparing a narrative report, first try and put yourself in the claim examiner’s position. Your goal is to describe what you did and why, in a writing style and tone of an explanation to a friendly colleague. A good report is a clear and concise narrative that includes, as needed:

• Clinical condition of the oral cavity

• Description of the procedure performed

• Specific reasons why the procedure was needed, or extra time or material was needed

• How new technology enabled delivery

• Specific information required by a participating provider contract

Both the ADA Dental Claim Form and the HIPAA standard electronic dental claim transaction support transmittal of your narrative. If the “Remarks” field on the paper form does not provide enough space for you to say what you need to say, additional sheets may be included. Check with your practice management system vendor to learn how a narrative is included on your electronic claim submission.

Clarity is crucial. Do not assume that the reader will be familiar with acronyms or abbreviations you use on your patient records. Be sure to proofread the text before inclusion with the claim submission.

What do you think of this “by report” narrative?

It is a real-life example – shown exactly as submitted – that looks more like quickly written notes from the patient’s record, with acronyms, misspellings and abbreviations that may confuse the reader. The entire claim was returned unprocessed.

Acronyms, abbreviations, and misspelled words hinder understanding. Narrative templates should be avoided, but if used the dentist remains obligated to review and approve the completed work before submission.

Now let’s look at how the returned report narrative might have looked if written clearly.

This is a clear and concise report that answers the “What and Why” questions the claims reviewer will be asking. It establishes clinical need and the procedure’s positive outcome as expected.

CDT Code Maintenance: Additions, Revisions and Deletions

The ADA’s Council on Dental Benefit Programs (CDBP) is responsible for CDT Code maintenance. In 2012, it established its Code Maintenance Committee (CMC), which convenes annually to vote on CDT Code action requests. Accepted requests are incorporated into the next version, which is effective on January 1st yearly.

Features of the maintenance process now in place are:

1. The CMC, a 21-member body comprised of representatives from numerous sectors of the dental community (such as third-party payers and dental specialties, including public health dentistry), that votes to accept, amend or decline a CDT Code action request.

2. A summary of action requests to be addressed at each CMC meeting is posted for download on ADA.org, including information on how to obtain a copy of the complete request form.

3. During a CMC meeting the chair encourages submitters of action requests and any other interested party to voice their comments on any requests to the committee’s members.

4. During a CMC meeting the committee members discuss action requests and cast their votes.

5. The ADA Council on Dental Benefit Programs sends notices of action taken to each person or entity that submitted a CDT Code action request and posts the results on ADA.org.

Please visit the ADA’s web page ADA.org/cdt for more information.

The CDT Code changes for many reasons, including technology or materials that have led to new procedures not currently in the taxonomy, or the need to improve clarity and accuracy of nomenclature and descriptors. Anyone may submit an action request.

For further assistance please contact the ADA Member Service Center at 312.440.2500.

Dental Procedure Codes (CDT) and Diagnosis Codes (ICD)

Dentists, through education and experience, diagnose a patient’s oral health prior to treatment plan preparation and delivery of necessary dental services. However, for diagnoses, codified clinical documentation or reporting on a dental claim is not a routine activity. Change is afoot and your colleagues on the ADA Council on Dental Benefit Programs offer a look ahead to help you prepare for documenting and reporting diagnosis codes if and when required.

Both the ADA Dental Claim Form and the HIPAA standard electronic dental claim transaction are able to report up to four diagnosis codes. This capability was added to the claim forms with the expectation that ICD (International Classification of Diseases) would, at some point, become a required data element for dental claim adjudication.

Why should dentists be concerned with ICD codes when the ADA has developed SNODENT?

SNODENT is a clinical terminology designed for use with electronic health records, and it differs from ICD in three ways:

1. It is an input code set.

2. It has broader scope and specificity.

3. It may be mapped to ICD as needed on a dental claim.

Federal regulations published under the auspices of HIPAA’s Administrative Simplification provisions specify only ICD codes as valid on claim submissions.

Most – but not all – diagnoses will be reported using an entry from the “Diseases of Oral Cavity” in ICD-10-CM (K00 – K14 series). ICD-10-CM became the HIPAA standard on October 1, 2015. It is a code set maintained by federal government agencies and available online at no cost.

The full file download is available here:

cms.gov/Medicare/Coding/ICD10/2017-ICD-10-CM-and-GEMs.html

Dentists and their staff are urged to familiarize themselves with the particulars of patients’ dental benefits plans claim preparation and submission requirements. In addition, pay close attention to communications from dental plans regarding additional benefits for services connected to systemic health or about dental plans’ intentions to require diagnostic codes on dental claim submissions.

Note: There is no immediate and universal mandate to include an ICD-10-CM code on all dental claims. We also emphasize that dental benefit plans are unlikely to establish identical diagnostic code reporting requirements. You should check with each plan for its requirements.

Section 3 contains the appendix titled “CDT Code to ICD (Diagnosis) Code Cross-Walk,” an aid to recordkeeping and claim preparation. Tables in this appendix link frequently reported CDT Codes with one or more possible ICD-10-CM diagnostic codes. Please note that these tables are not all inclusive but do serve as a guide for commonly occurring conditions.

Note: Several chapters in Section 2 include additional information on ICD-10-CM codes pertinent to the procedures listed in the CDT Code’s category of service.

Dentists, by virtue of their clinical education, experience, and professional ethics, are the individuals responsible for diagnosis. As such, a dentist is also obligated to select the appropriate diagnosis code for patient records and claim submission. It is quite possible that other diagnoses and their associated codes may be appropriate for a given clinical scenario.

As you study these tables please note:

1. Some address a single CDT Code (e.g., preventive resin restoration), and others include a suite of related procedure codes (e.g., resin-based composite).

2. Likewise, the number of suggested ICD-10-CM diagnosis codes in a table can range from one (e.g., gingival recession for eight graft codes) to more than 10.

3. Several contain suggested diagnosis codes that are not from the “Diseases of the Oral Cavity” section ICD-10-CM; there are circumstances (e.g., vehicle accidents, workers compensation) where other sections of the ICD code set has pertinent entries.

4. Some ICD code terms contain words that are not commonly used in the US. These words, identified by an asterisk (*), are defined in the ADA online glossary: ADA.org/en/publications/cdt/glossary-of-dental-clinical-and-administrative-ter.

Similar CDT to ICD tables are posted in the ADA’s Center for Professional Success (CPS) website at success.ada.org/en/dental-benefits/icd-and-cdt-codes.

These online tables may be updated more frequently than those in print as changes to ICD-10-CM occur on a schedule that differs from the CDT Code’s timetable.

Dental Procedure Codes vs. Medical Procedure Codes

The CDT Code is the source for procedure codes used when submitting claims to dental benefit plans on either the ADA Dental Claim Form or the HIPAA standard electronic dental claim transaction. There may be times when a dentist’s services are submitted to a patient’s medical benefit plan. When this happens, not only is there a different claim form, but there are also different procedure codes that must be used. None of these are developed or maintained by the ADA.

Filing claims with a patient’s medical benefit plan can be done using the “1500” paper form or HIPAA electronic equivalent. Information on the 1500 Claim Form, including completion instructions, can be found at the American Medical Association’s (AMA) National Uniform Claim Committee website www.nucc.org.

Medical procedure codes come from two sources, the AMA’s Current Procedure Terminology (CPT) code set and the federal government’s Healthcare Common Procedure Code Set (HCPCS). All medical diagnosis codes come from the federal government’s International Classification of Diseases-10th Revision-Clinical Modification (ICD-10-CM) code set.

Note: When selecting a medical procedure code, the rule of thumb is to first look at the CPT code set to determine if there is an appropriate code to use. If there is none, a HCPCS code may be used.

Sources for medical procedure codes include, but are not limited to:

1. American Medical Association

https://commerce.ama-assn.org/store

800.621.8335

2. Centers for Medicare and Medicaid Services (HCPCS)

www.cms.hhs.gov/HCPCSReleaseCodeSets

Sources for ICD-10-CM diagnosis codes include, but are not limited to:

1. National Center for Health Statistics

www.cdc.gov/nchs/icd.htm

2. ADA Catalog

Diagnostic Coding for Dental Claim Submission by Charles Blair, D.D.S.

ADAcatalog.org

800.947.4746

3. PMIC Coding and Compliance

http://icd10coding.com

Sources of dental to medical procedure cross coding information include, but are not limited to:

1. ADA Catalog

Medical Cross Coding with Confidence by Charles Blair, D.D.S.

ADAcatalog.org

800.947.4746

2. Udell Webb Leadership Institute

www.webbdental.com/dental_MEDICAL_cross_coding_insurance_codes.html

877.628.3366

3. The Art of Practice Management

www.artofpracticemanagement.com/cross_coding_questions.htm www.artofpracticemanagement.com/products.htm

252.637.6259

Claim Rejection: Payer Misuse of the CDT Code or Something Else?

Some claims will be rejected by a third-party payer and the reason for denial helps determine what should be done next. “The existence of a dental procedure code does not mean that the procedure is a covered or reimbursed benefit,” is a quote from the preface of the first (1990) and every later edition of the CDT manual. This is an important concept as available coverage is determined by dental benefit plan design. Plan limitations and exclusions vary, which means a procedure that is covered by one patient’s benefit plan may not be covered by another patient’s plan.

In August 2000, HIPAA (Health Insurance Portability and Accountability Act of 1996) Subtitle F (Administrative Simplification) regulations named the Code on Dental Procedures and Nomenclature (CDT Code) as the federal standard for reporting dental procedures on electronic dental claims. Some have interpreted this to mean that since the CDT Code is a national standard, payers must provide reimbursement for any valid procedure code reported on a claim. This is an erroneous interpretation as the HIPAA regulations are limited to four statements:

1. A standard electronic dental claim may only contain procedures found in the CDT Code.

2. A dentist must submit the procedure code that is valid on the date of service.

3. A payer may not refuse to accept for processing a claim with a valid procedure code.

4. A payer’s benefit plan design and adjudication policies apply when processing a claim.

In other words, HIPAA establishes a standard for communicating information about services provided to a patient. HIPAA does not influence a payer’s claim adjudication process (e.g., application of policies and benefit limitations and exclusions).

An explanation of benefits that shows reimbursement for fewer services or for different procedure codes than reported on the claim raises eyebrows and prompts dentists to call the ADA and ask, “How can this happen? Isn’t the third-party payer doing something wrong or illegal? It looks like the CDT Code is being misused.” The first step in answering these questions and concerns is to look at what guidance is in place concerning CDT Code use:

• A third-party payer is supposed to use the code number (e.g., D0120), its nomenclature and its descriptor as written.

• The ADA defines procedure code bundling as “the systematic combining of distinct dental procedures by third-party payers that results in a reduced benefit for the patient/beneficiary.” Procedure code bundling is frowned upon by the ADA.

However, dentists who have signed participating provider agreements with third-party payers may be bound to plan provisions that limit or exclude coverage for concurrent procedures.

• The Health Insurance Portability and Accountability Act (HIPAA) requires the procedure code reported on a claim be from the CDT Code version that is effective on the date of service. Yet neither HIPAA, ADA policy nor the CDT Code itself require that a third-party payer cover every listed dental procedure.

• Covered dental procedures are identified in the contract between the plan purchaser and the third-party payer.

Many patients do not understand how dental benefit programs work and that coverage limitations and exclusions may limit reimbursement for necessary care. Such a misunderstanding is compounded when EOB language suggests that the dentist is at fault. Ensuring patients understand the limitations of their dental plan prior to treatment may help avoid problems and maintain a strong dentist-patient relationship.

Some dental claim adjudication practices are appropriate when based on plan design and should be clearly explained on the EOB to prevent misunderstandings. Other situations, where the EOB message suggests the dentist is in error, may pose problems. Each of these conditions is illustrated in the following examples:

• Acceptable EOB explanation: A claim for a “D4355 full mouth debridement” and a two- surface restoration is adjudicated, and only the D4355 is reimbursed. The EOB message states that the benefit plan has limitations and exclusions, one of which is that the plan does not cover any restorative procedure delivered on the same day as a D4355. In this example, the payer has not paid for the procedure due to benefit plan design limitations – there is no suggestion that the dentist has done anything improper.

• Unacceptable EOB explanation: The dentist reports a D1110 on the claim because the patient is 13 years old with predominantly adult dentition, but the EOB lists D1120 with a message that this is the correct code for a patient under the age of 15. In this example, the payer is wrong, as the message implies that the dentist reported the incorrect prophylaxis procedure code.

Here the payer ignored the CDT Code’s descriptor where dentition, not age, is the criterion for reporting an adult versus child prophylaxis. What the payer should do when the benefit plan specifies an age-based benefit limitation is accept the claim as submitted and note on the EOB that the claim has been adjudicated based on benefit plan design.

The second example illustrates why it is important that the dental office help the patient understand the clinical basis for treatment. In this case, the type of prophylaxis is determined by the state of the patient’s dentition, not age, even though the patient’s benefit may be determined by age.

Dental benefit plan limitations and exclusions affect how a claim is adjudicated and, as noted above, a payer may reject or not reimburse a claim in accordance with the benefit plan’s provisions. Just as benefit plan designs vary, there is variation in participating provider contract provisions, and if you have one (or more) each must be reviewed to see how claim submission and processing may be affected. The ADA Contract Analysis Service, an ADA member benefit, can identify areas of provider contract provisions that may be of concern and be addressed before signing the contract. More information on the Contract Analysis Service is available here: ADA.org/en/member-center/member-benefits/legal-resources/contract-analysis-service.

Participating provider contracts are between the dentist and payer. These contracts may include provisions that require you to accept least expensive alternative treatment (LEAT) reimbursement, or agree to reimbursement based on payer guidelines instead of specific procedure codes reported on a claim. A dentist who signs a participating provider contract is generally bound to its legally sound provisions. Likewise, the payer is also bound to the contract provisions and cannot obligate you to do something that is beyond the signed agreement.

It is appropriate to appeal the benefit decision if you think the claim has not been properly adjudicated. When appealing a claim, it is important to follow the specific instructions provided by the particular carrier including the submittal of the appeal in writing within the time allowed by the carrier. It is important to send it to the specified department of the carrier and it must be in the required format. The word “appeal” should prominently appear in the title and text of the document, as well as in any cover letter that accompanies the appeal document.

Remember, the dentist consultant representing the carrier may only be looking at a dental claim form and you will want to provide the consultant as much information as possible so that he or she will agree with your treatment plan and approve the appropriate benefits for your patient.

A proper appeal involves sending the carrier a written request to reconsider the claim. Additional documentation should be included to give the carrier a clearer picture of why you recommended the treatment. For example, the following claim attachments may assist in getting consideration for core buildup claims – radiographic evidence of the need for a buildup, and a narrative description providing as much explanatory information as possible (even if this appears obvious to you). If you have further questions, it is best to give that carrier a call.

Remember, you are trying to have the dentist consultant understand the rationale for your recommended treatment plan so that your patient can receive the appropriate benefit from his or her plan.

It may help to ask the dentist consultant to call you if the claim is going to be denied. This way you can discuss the case with the dentist consultant on a professional level. You may want to leave a time and date when you will be available so that the consultant does not call while you are seeing patients.

Payers using the CDT Code must be licensed to do so – and abide by the copyright license. Any payer actions that do not adhere to contractual obligations may represent misuse, and be reason to seek redress. The copyright license does not dictate how a procedure code is to be reimbursed and cannot be used as a tool to force payers to use the CDT Code in a particular manner.

However, arbitrary payer action is an ongoing ADA concern and we ask that dentists report such actions so that staff can address recurring issues with the third-party payer involved. Also, it is appropriate to appeal the benefit decision if you think the claim has not been properly adjudicated, and ADA staff is prepared to assist in your understanding of the appeal process.

Even if an objectionable use of the Code is not a license violation or illegal, ADA staff remains available to contact third-party payers, attempting to discuss the issues and to resolve potential conflicts. Dentist reports of concerns enable ADA staff to address individual issues with payers, as well as providing the means to determine, monitor and address patterns of payer actions.

Note: The ADA Member Service Center (MSC) is your first point of contact when you have questions about the CDT Code and its use, or to report possible third-party payer “misuse.” Please contact the MSC by telephone at 312.440.2500.

If you wish to simply alert the ADA to a concern, you can complete the downloadable form on ADA.org titled, “third-party payer complaint form” which gives dental offices the opportunity to provide information on the problems experienced with third-party payers.

This form was developed by the ADA Center for Dental Benefits, Coding and Quality to track industry trends and facilitate discussions with dental benefit plans and benefits administrators. The form is available online at: success.ada.org/en/dental-benefits/online-third-party-form.

The “Golden Rules” of Procedure Coding

Correct coding, part and parcel of the following rules, demonstrates a dentist’s adherence to the ADA’s Principles of Ethics and Code of Professional Conduct, particularly “5.A. Representation of Care” that states “Dentists shall not represent the care being rendered to their patients in a false or misleading manner.”

• “Code for what you do” is the fundamental rule to apply in all coding situations.

• After reading the full nomenclature and descriptor, select the code that matches the procedure delivered to the patient.

• If there is no applicable code, document the service using an unspecified, by report (“999”) code, and include a clear and appropriate narrative.

• The existence of a procedure code does not mean that the procedure is a covered or reimbursed benefit in a dental benefit plan.

• Treatment planning is based on clinical need, not covered services.

If you have difficulty finding an appropriate CDT Code consider whether there may be another way to describe the procedure. The CDT Manual’s alphabetic index, and the glossary of dental terms posted on ADA.org are likely to be helpful in these situations.

Code Changes in CDT 2018

The number and nature of annual CDT Code changes vary, as does their relevance to an individual dentist vary – primarily based on her or his type of practice. CDT 2018 incorporates a variety of substantive CDT Code entry actions – 18 additions, 16 revisions, and three deletions – summarized in the following table.

Code	• = Addition = Revision # = Deletion
I. Diagnostic
D0411	Addition
II. Preventive
D1354	Revision
D1555	Revision
III. Restorative
D2740	Revision
IV. Endodontics
D3320	Revision
D3330	Revision
D3347	Revision
D3421	Revision
D3426	Revision
V. Periodontics
D4230	Revision
D4231	Revision
D4355	Revision
VI. Prosthodontics (removable)
D5510	Deletion
D5511	Addition
D5512	Addition
D5610	Deletion
D5611	Addition
D5612	Addition
D5620	Deletion
D5621	Addition
D5622	Addition
VII. Maxillofacial Prosthetics
None
VIII. Implant Services
D6081	Revision
D6096	Addition
D6118	Addition
D6119	Addition
IX. Prosthodontics, fixed
None
X. Oral and Maxillofacial Surgery
D7111	Revision
D7296	Addition
D7297	Addition
D7979	Addition
D7980	Revision
XI. Orthodontics
D8695	Addition
XI. Adjunctive General Services
D9222	Addition
D9223	Revision
D9239	Addition
D9243	Revision
D9995	Addition
D9996	Addition

There were no requested CDT 2018 editorial actions (such as changes in syntax or spelling) that clarify a CDT Code entry without changing its purpose or scope.

Some of the CDT 2018 changes listed in this table are stand alone and others – additions with associated revisions or deletions – are interrelated. These changes will be addressed in detail within the following chapters.

Notable Changes: What and Why

There are several notable changes that reflect how the CDT Code evolves to accommodate procedure documentation needs by adding new or revising existing code entries. The nine notable changes and rationales for their inclusion in CDT 2018 follow in category of service order. These changes are color coded (new text in blue underline; deleted text in red strike-through).

D0100-D0999 Diagnostic

New entry:

D0411 HbA1c in-office point of service testing

Rationale for the addition:

Simple chair-side screening for dysglycemia via finger-stick random capillary HbA1c glucose testing can be used to rapidly identify high-risk patients. Chair-side screening and appropriate referral may improve diagnosis of pre-diabetes and diabetes.

A code for the finger-stick capillary HbA1c glucose test procedure will assist in broader adoption of this practice in certain dental settings and practices. In addition, it may facilitate further practice-based studies that will assist in demonstrating the acceptability, feasibility, effectiveness, and cost-effectiveness of chair-side diabetes screening.

Note: When the test result is positive a dentist should assess how this information affects the patients current and future treatment plans.

D2000-D2999 Restorative

Revised entry:

D2740 crown – porcelain/ceramic substrate

Rationale for the revision:

The porcelain/ceramic crown procedure has been in the CDT Code set since the first version was published in the Journal of the American Dental Association in 1969. The entry has consisted of the code and its nomenclature, unchanged, in all subsequent versions. No documentation that explains inclusion of “substrate” in the nomenclature has been discovered.

Removal of this word from the D2470 nomenclature brings consistency to the CDT Code, in particular the entry “D2783 crown – ¾ porcelain/ceramic” added to the code set in CDT-3, and unchanged in subsequent versions.

D4000-D4999 Periodontics

Revised entry:

D4355 full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit

The gross 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 preliminary procedure does not preclude the need for additional procedures. Not to be completed on the same day as D0150, D0160, or D0180.

Rationale for the revision:

If full mouth debridement is necessary, excessive calculus and plaque are present resulting in inflammation including edema and bleeding, which prevents a complete evaluation and diagnosis to be adequately performed. In these cases, some time for healing after debridement would be warranted to accurately assess the patient’s oral health and create a treatment plan.

D9000-D9999 Adjunctive General Services

Two related pairs of new and revised entries:

D9222 deep sedation/general anesthesia – first 15 minutes

Anesthesia time begins when the doctor administering the anesthetic agent initiates the appropriate anesthesia and non-invasive monitoring protocol and remains in continuous attendance of the patient. Anesthesia services are considered completed when the patient may be safely left under the observation of trained personnel and the doctor may safely leave the room to attend to other patients or duties.

The level of anesthesia is determined by the anesthesia provider’s documentation of the anesthetic effects upon the central nervous system and not dependent upon the route of administration.

D9223 deep sedation/general anesthesia – each subsequent 15 minute increment

Anesthesia time begins when the doctor administering the anesthetic agent initiates the appropriate anesthesia and non-invasive monitoring protocol and remains in continuous attendance of the patient. Anesthesia services are considered completed when the patient may be safely left under the observation of trained personnel and the doctor may safely leave the room to attend to other patients or duties.

The level of anesthesia is determined by the anesthesia provider’s documentation of the anesthetics effects upon the central nervous system and not dependent upon the route of administration.

D9239 intravenous moderate (conscious) sedation/analgesia – first 15 minutes

Anesthesia time begins when the doctor administering the anesthetic agent initiates the appropriate anesthesia and non-invasive monitoring protocol and remains in continuous attendance of the patient. Anesthesia services are considered completed when the patient may be safely left under the observation of trained personnel and the doctor may safely leave the room to attend to other patients or duties.

The level of anesthesia is determined by the anesthesia provider’s documentation of the anesthetic effects upon the central nervous system and not dependent upon the route of administration.

D9243 intravenous moderate (conscious) sedation/analgesia – each subsequent 15 minute increment

Anesthesia time begins when the doctor administering the anesthetic agent initiates the appropriate anesthesia and non-invasive monitoring protocol and remains in continuous attendance of the patient. Anesthesia services are considered completed when the patient may be safely left under the observation of trained personnel and the doctor may safely leave the room to attend to other patients or duties.

The level of anesthesia is determined by the anesthesia provider’s documentation of the anesthetics effects upon the central nervous system and not dependent upon the route of administration.

Rationale for the pairs of related additions and revisions:

New entries for the “first 15 minutes” reflect the initial administration of the anesthetic agent. Revisions to the existing entries enables documentation of subsequent 15 minute increments of anesthesia time. Eliminating the descriptors as part of these revisions is appropriate as references to start time are not applicable for subsequent time increments as the delivery of the anesthetic agent is already underway.

Two related new entries:

D9995 teledentistry – synchronous; real-time encounter

Reported in addition to other procedures (e.g., diagnostic) delivered to the patient on the date of service.

D9996 teledentistry – asynchronous; information stored and forwarded to dentist for subsequent review

Reported in addition to other procedures (e.g., diagnostic) delivered to the patient on the date of service.

Rationale for the two related additions:

In March 2015 the CMC declined a request for codes that would document patient encounters and services that involved the teledentistry delivery model. The committee’s rationale was that the location can be recorded in the Place of Service (POS) field on dental claim submission (paper and electronic).” POS codes, maintained by the Centers for Medicare and Medicaid Services, define the entity (location) where service(s) are rendered. Post-CMC meeting research reveals that no POS code is clearly and unambiguously linked to a service delivered by teledentistry.

Separate CDT Codes to document a synchronous and an asynchronous teledentistry encounter is an immediate solution that is consistent with the code set’s existing structure and current entries for professional visits (D9410-D9420), sales tax (D9985) and case management (D9991-D9994).

There are 28 other substantive changes in CDT 2018. Each is on the following list and will be fully addressed in its applicable CDT 2018 Companion category chapter:

Chapter	Substantive Change
	D1354 interim caries arresting medicament application – per tooth Conservative treatment of an active, non-symptomatic carious lesion by topical application of a caries arresting or inhibiting medicament and without mechanical removal of sound tooth structure.
Preventive	D1555 removal of fixed space maintainer Procedure delivered performed by dentist or practice that who did not originally place the appliance, or by the practice where the appliance was originally delivered to the patient.
	D3320 endodontic therapy, premolar bicuspid tooth (excluding final restoration)
	D3330 endodontic therapy, molar tooth (excluding final restoration)
	D3347 retreatment of previous root canal therapy – bicuspid premolar
Endodontics	D3421 apicoectomy – bicuspid premolar (first root) For surgery on one root of a bicuspid premolar. Does not include placement of retrograde filling material. If more than one root is treated, see D3426.
	D3426 apicoectomy – (each additional root) Typically used for bicuspids premolar and molar surgeries when more than one root is treated during the same procedure. This does not include retrograde filling material placement.
	D4230 anatomical crown exposure – four or more contiguous teeth or bounded tooth spaces per quadrant This procedure is utilized in an otherwise periodontally healthy area to remove enlarged gingival tissue and supporting bone (ostectomy) to provide anatomically correct gingival relationship.
Periodontics	D4231 anatomical crown exposure – one to three teeth or bounded tooth spaces per quadrant This procedure is utilized in an otherwise periodontally healthy area to remove enlarged gingival tissue and supporting bone (ostectomy) to provide an anatomically correct gingival relationship.
	D5511 repair broken complete denture base, mandibular
	D5512 repair broken complete denture base, maxillary
	D5611 repair resin partial denture base, mandibular
	D5612 repair resin partial denture base, maxillary
Prosthodontics, fixed	D5621 repair cast partial framework, mandibular
	D5622 repair cast partial framework, maxillary
	D5510 repair broken complete denture base
	D5610 repair resin denture base
	D5620 repair cast framework
	D6096 remove broken implant retaining screw
Implant Services	D6118 implant/abutment supported interim fixed denture for edentulous arch – mandibular Used when a period of healing is necessary prior to fabrication and placement of a permanent prosthetic.
	D6119 implant/abutment supported interim fixed denture for edentulous arch – maxillary Used when a period of healing is necessary prior to fabrication and placement of a permanent prosthetic.
	D6081 scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure This procedure is not performed in conjunction with D1110, or D4910, or D4346.
	D7296 corticotomy – one to three teeth or tooth spaces, per quadrant This procedure involves creating multiple cuts, perforations, or removal of cortical, alveolar or basal bone of the jaw for the purpose of facilitating orthodontic repositioning of the dentition. This procedure includes flap entry and closure. Graft material and membrane, if used, should be reported separately.
Oral and Maxillofacial Surgery	D7297 corticotomy – four or more teeth or tooth spaces, per quadrant This procedure involves creating multiple cuts, perforations, or removal of cortical, alveolar or basal bone of the jaw for the purpose of facilitating orthodontic repositioning of the dentition. This procedure includes flap entry and closure. Graft material and membrane, if used, should be reported separately.
	D7979 non – surgical sialolithotomy A sialolith is removed from the gland or ductal portion of the gland without surgical incision into the gland or the duct of the gland; for example via manual manipulation, ductal dilation, or any other non-surgical method.
	D7111 extraction, coronal remnants – primary deciduous tooth Removal of soft tissue – retained coronal remnants.
	D7980 surgical sialolithotomy Procedure by which a stone within a salivary gland or its duct is removed, either intraorally or extraorally.
Orthodontics	D8695 removal of fixed orthodontic appliances for reasons other than completion of treatment