D0100 – D0999 Diagnostic
By Mark Mihalo, D.D.S.
Introduction
Could you imagine doing a crown prep without a high speed handpiece? Sixty years ago this was the norm, but just as our dental equipment has changed so have our diagnostic abilities. Radiographic film has given way to sensors. Sensors can gather and combine multiple images to create a single image that can be two or even three dimensional. What has not changed is the need to have a thorough and comprehensive diagnosis that will greatly enhance proper treatment and, consequently, a good prognosis.
Key Definitions and Concepts
Evaluation: The systematic determination or judgment about a condition, disease or treatment
Imaging: Creating a visual representation of the interior of a body revealing inner structure that may have been blocked by skin or bone
Intraoral image: A visual representation of the mouth derived by placing a film, plate or sensor within the mouth
Extraoral image: A visual representation of the mouth derived by placing a film, plate or sensor outside the mouth
Changes to This Category
One code was added in CDT 2018’s Diagnostic Category:
D0411 HbA1c in office point of testing
This code is used when drawing a pin-prick blood sample and performing point of service analysis of the sample.
There were no revisions, deletions, or editorial changes.
Diagnosis Codes – ICD-10-CM
The CDT to ICD tables in Appendix 1 provide appropriate guidance on linkages between Diagnostic procedure codes and diagnosis codes. Please note that the International Classification of Disease (ICD) is a code set where letters and numbers are given to every diagnosis, description of symptoms and causes of death attributed to the human species, and ICD-10-CM went in to use October 1, 2015. Dentists should know that ICD coding is becoming more accepted by state Medicaid programs with some states requiring the use of an ICD code for the diagnosis along with a CDT code when dental treatment is rendered. The current ADA Dental Claim Form and the HIPAA standard electronic dental claim transaction can report up to four diagnosis codes.
CODING SCENARIO #1
Patient Age 11 – Evaluation and Preventive Services
A new patient, age 11, was seen for a first exam, cleaning, and fluoride application. During the exam the dentist noted that the erupting tooth #4 was impinging on the band loop spacer that another dentist cemented to #3, and decided to remove it.
How might this visit be coded?
D0150 comprehensive oral evaluation – new or established patient
D1120 prophylaxis – child
D1208 topical application of fluoride – excluding varnish
D1555 removal of fixed space maintainer
Note: If in this scenario the topical fluoride was a varnish, D1208 would not be correct. The appropriate CDT Code would be:
D1206 topical application of fluoride varnish
What if the same patient was not new and the doctor had placed the space maintainer two years ago. How would this encounter be coded?
D0120 periodic oral evaluation
D1120 prophylaxis – child
D1208 topical application of fluoride – excluding varnish
The exam, in this case, would be periodic (D0120) because the patient was seen previously, but the prophylaxis and fluoride codes remain the same. D1555 is not used to report space maintainer removal in this alternative scenario as the code’s descriptor specifies that it is for a dentist who did not place the space maintainer.
New Patient Who Uses Tobacco
A 21-year-old new patient is seen for a first exam. You note that he has numerous decayed anterior and posterior teeth but when you attempt to take a full mouth intraoral series of radiographs you discover he has a severe gag response. You take a panoramic image and extra-oral bitewings (right and left). He is also a heavy chew tobacco user so you perform a tissue fluorescence oral cancer exam and spend about 15 minutes discussing his tobacco use, what it is doing to his mouth, and his options to try to quit.
How would you code this visit?
D0150 comprehensive oral evaluation
D0330 panoramic radiographic image
D0251 extra-oral posterior radiographic image
Choosing the panoramic (D0330) and extra-oral bitewing (D0251) radiographs allowed you to get a good understanding of his oral conditions. Report D0330 once as it is a single image, and D0251 twice as there are separate right and left images.
D0431 adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures
D1320 tobacco counseling for the control and prevention of oral disease
Examples of cytology or biopsy procedures may include Velscope or Vizilite. This test is done in addition to your normal visual and palpation exam that is part of a comprehensive evaluation.
Child Under Three – Evaluation and Parent Counseling, and Preventive Services
The American Academy of Pediatric Dentistry and the ADA advise that children should have their first dental visit within six months of the eruption of the first primary tooth. The doctor performed an intraoral examination while the mother restrained the child’s forehead in her lap. The dentist could determine that the child had maxillary and mandibular primary central incisors and that they were free of decay. He also removed plaque using an ultra-soft toothbrush and applied fluoride varnish. The doctor also explained to the parent how to use a wash cloth or soft brush to remove plaque each day and the importance of getting her child to go to sleep without a bottle. They discussed foods that can lead to decay and recommended that she return in a year for an exam after most of the primary teeth have erupted.
To summarize, this is what occurred during the office visit:
• Oral examination
• Toothbrush deplaquing
• Fluoride varnish
• Discussion of diet and preventive care with her mother
How would you code this initial visit?
The initial visit would be coded using:
D0145 oral evaluation for a patient under three years of age and counseling with primary caregiver
D1120 prophylaxis – child
D1206 topical application of fluoride varnish
Note: The evaluation and counseling code (D0145):
• has both diagnostic and preventive characteristics
• is specifically for children under three years of age
• includes an evaluation of oral conditions, history, and caries susceptibility
• includes development of an oral hygiene regimen
• always includes counseling the primary caregiver or parent
What evaluation code could be used on the next visit?
Either the evaluation and counseling code (D0145) or the periodic evaluation (D0120) could be used for the next visit. There is nothing in D0145’s nomenclature or descriptor that precludes its use for another visit, as long as the patient is still under three years of age and all the components of the procedure are completed. The periodic exam might be appropriate as the primary dentition develops and if the other criteria are not met. The prophylaxis and fluoride would remain the same.
Radiographs – What Constitutes a Full Mouth Series?
A change published in CDT 2009 added a descriptor to procedure code D0210 that defined a complete mouth series of radiographic images. The descriptor was drawn from The Selection of Patients for X-Ray Examinations: Dental Radiographic Examinations published by the FDA in 2004.
With this in mind, consider how radiographs for patients A, B and C are documented.
Patient A is missing all second and third molars.
The office takes ten periapical x-rays: three upper anterior, three lower anterior and one posterior in each quadrant.
If the radiographs display the crowns and roots of all teeth, periapical areas and alveolar bone crest, the full mouth series procedure code would be appropriate. D0210 includes bitewings when indicated, but bitewings are not a required component of this procedure.
D0210 intraoral – complete series of radiographic images
A radiographic survey of the whole mouth, usually consisting of 14-22 periapical and posterior bitewing images intended to display the crowns and roots of all teeth, periapical areas and alveolar bone.
If the radiographs do not display all these structures, the applicable procedure codes are:
D0220 intraoral – periapical first radiographic image (reported once)
D0230 intraoral – periapical each additional radiographic image (reported nine times)
Patient B has all her teeth and has impacted partially erupted third molars.
The office takes a panoramic x-ray and four posterior bitewings.
D0330 panoramic radiographic image
D0274 bitewings – four radiographic images
Since a panoramic radiographic image is not intraoral, this combination could not correctly be reported as a full mouth series (D0210).
Note: The ADA Council on Dental Benefit Programs receives many calls that claims for D0330 and D0274 are downcoded by third-party payers to D0210 for purposes of reimbursement. This term is defined in the Glossary published on ADA.org:
downcoding: A practice of third-party payers in which the benefit code has been changed to a less complex and/or lower cost procedure than was reported, except where delineated in contract agreements
Patient C has a maxillary full denture and fourteen mandibular teeth.
The office takes four periapicals of the upper edentulous ridge, seven periapicals of the lower arch and four posterior bitewings. This situation, while not the most common scenario, does meet all the criteria for and is correctly coded as a full mouth series.
D0210 intraoral – complete series of radiographic images
A radiographic survey of the whole mouth, usually consisting of 14-22 periapical and posterior bitewing images intended to display the crowns and roots of all teeth, periapical areas and alveolar bone.
Please remember, as noted for Patient A, D0210 includes bitewings when indicated, but they are not a required component of this procedure.
Regardless of the benefit plan possessed by a patient, the reporting of performed procedures should always reflect what treatment was provided. Alternate payment provisions may apply, but the third-party should send statements to patients and providers alike that explain why an alternate benefit was provided.
Dentists who have signed provider agreements with third-party payers should check their contracts to see if there are provisions that apply to this situation.
Oral Cancer – An Enhanced Examination
An oral cancer evaluation is included in the descriptors of both of the comprehensive oral evaluations (D0150 and D0180) and the periodic oral evaluation (D0120). Visual inspection using operatory lighting and palpation are the techniques that are frequently used in routine oral cancer evaluations. A dentist may decide that patients with increased cancer risk factors should also receive an enhanced oral cancer examination, one that is more extensive than a routine oral cancer screening and may include the use of additional diagnostic aids.
How could the dentist report use of additional diagnostic aids in the oral cancer examination?
There is not an independent code for an enhanced oral cancer examination, but there is a code that can be used when some type of staining or adjunctive procedure is performed:
D0431 adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures
This code would be used to report the use of chemiluminescent testing (e.g., Vizilite®) or any intra-oral staining technique (e.g., toluidine blue).
If the additional procedures are not described by D0431 the dentist could use:
D0999 unspecified diagnostic procedure, by report
D0999 can be used to report any diagnostic procedure which does not seem to be included in the CDT Code. A narrative that describes the service must be included on the claim when this code is used.
Orthognathic Surgery Planning
An oral and maxillofacial surgery office recently installed a cone beam radiography machine. It was used to treatment plan some anticipated orthognathic surgery for a patient. Following image capture, several axial and lateral views were consulted to plan the surgery. A panoramic view was also produced to send to the patient’s orthodontist.
After consultation with the orthodontist, the surgeon constructed a 3D virtual model, which they viewed together on the computer, to properly locate a temporary implant to anchor the orthodontic appliance. The virtual model could be manipulated on the screen to allow them to visualize other anatomical structures in the area and their relationship to the teeth to determine the ideal location to place the implant.
A transmucosal endosseous implant was placed as a temporary fixation device for the patient’s braces. The temporary implant will be removed when orthodontic treatment is completed.
How could you code the initial treatment planning visit’s diagnostic imaging procedures?
D0367 cone beam CT capture and interpretation with field of view of both jaws; with or without cranium
This code was added effective January 1, 2013 specifically to report procedures related to cone beam imaging technology. It replaced the separate cone beam data capture (D0360) and two-dimension reconstruction (D0362) codes. The image capture includes two-dimensional sectional (tomographic) views from the axial (coronal or frontal) and lateral (sagittal) planes, as well as the panoramic view.
How could you code the subsequent consultation? (3D virtual model)
D0393 treatment simulation using 3D image volume
The 3D virtual model is a three-dimensional image reconstructed from data acquired during the treatment planning visit.
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