D1000 – D1999 Preventive
By Paul Bornstein, D.M.D.
The topic of preventive dentistry is unique in that it really intermixes with many other categories of service. To understand preventive, you must be able to compare various treatment scenarios in other categories, most notably periodontal and diagnostic. The Preventive category is perhaps the perfect group of codes to help describe the problems of coding and explain why whoever codes a procedure must pay strict attention to the literal definition of the code.
The key to billing correctly is to select the CDT Code whose definition best matches the procedure delivered.. This is important as there may be a number of codes to select from that may fit your treatment scenario. Good record keeping may help you if legal action arises. When it comes to record keeping, the more detail, the better.
A frequent key statement that the reader should remember is “There is no language in the descriptor that precludes the reporting of other procedures.” You may not be reimbursed, but you may bill the procedure if your records reflect the fact that it was performed. Many dental benefit plans require you to bill for all procedures regardless of possible payment if your office participates in the dental benefit plan program.
Prophylaxis adult: Removal of plaque and stains from the tooth structures in the permanent and transitional dentition. It is intended to control local irritational factors.
Prophylaxis is the treatment of gingivitis, not periodontal disease, which is defined by the loss of attachment including bone loss.
Topical application of fluoride varnish: Fluoride varnish must be applied separately from prophy paste.
Preventive resin restoration in a moderate to high caries risk patient – permanent tooth: Conservative restoration of an active cavitated lesion in a pit or fissure that does not extend into dentin; includes placement of a sealant in any radiating non-carious fissures or pits. This procedure differs from a sealant as it treats a cavitated lesion. It is delivered and reported when the lesion has not passed into dentin.
Sealant – per tooth: Mechanically or chemically prepared enamel to prevent decay. Use of a sealant connotes there is no decay.
The two CDT 2018 changes are revisions. No deletions or additions were made.
The revisions are:
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.
The words “per tooth” have been added to better define the procedure’s scope.
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.
Again the changes were made to better define the procedure reported with this code.
Diagnosis Codes – ICD-10-CM
The CDT to ICD tables in Appendix 1 provide appropriate guidance on linkages between Preventive procedure codes and diagnosis codes. This chapter does not contain supplemental information on this topic.
Patient Age Nine – Preventive Services
A new patient, in grade school, was seen for a first exam, cleaning, and fluoride gel application.
How might this visit be coded?
D0150 comprehensive oral evaluation – new or established patient
D1120 prophylaxis – child
D1208 topical application of fluoride – excluding varnish
What would change if the patient was 12 years old?
Selection of the prophylaxis code is determined by how the dentist views the patient’s dentition. Either the adult or the child code can be used for patients with transitional dentitions regardless of age. Patient age is not a part of either code’s nomenclature or descriptor. ADA policy recommends that dental benefit determinations should be based on dental development rather than patient age. According to the ADA Policy “Age of Child” adopted in 1991:
• Benefits should be based on stage of dentition
• If a plan cannot recognize stage of dentition, age 12 should be recognized as the age of an adult, in terms of dentition (with the exclusion of treatment for orthodontics and sealants).
The prophylaxis codes are dentition-specific rather than age-specific. Some third-party payers have restrictions in their contracts that limit available benefits based on age, not stage of dentition. Most dental benefit plans specify an age between 12 and 21, when the patient is considered an adult.
Regardless of age, patients with permanent dentition are appropriately coded using D1110 and D1208. In this case, if third-party payers substitute a procedure for a child during processing, it would be considered downcoding for purposes of reimbursement.
From 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.
An example of typical language from a dental benefits plan might be:
If an alternate treatment can be performed to correct a dental condition, the maximum covered dental expense we will consider for payment will be the most economical treatment which will, as determined by us, produce a professionally satisfactory result.
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 mother restrained the child’s forehead in her lap. The dentist was able to 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
• Caries risk assessment
• Dental prophylaxis
• Oral hygiene instructions with primary caregiver
• Application of topical fluoride varnish
• Dental anticipatory guidance
• Establishment of recall schedule
What is considered “Dental Anticipatory Guidance?”
Dental anticipatory guidance is age appropriate information/education for parents/caregivers based on:
• Questionnaire responses
• Parent/caregiver interview
• Caries risk assessment
• Multi-topic overview of oral health environmental influences
• Directed at increasing the parents’/caregivers’ understanding about the importance of good oral health
What would be generally considered the best documentation to support billing D0145? Use your best efforts to document as much as you can.
• Date of first dental home visit
• Name of primary caregiver present during first dental home visit
• What took place during visit:
1. Completion of oral health questionnaire by the dentist or a member of the dentist’s staff
2. The dental risk assessment questionnaire by the parent/guardian
3. Review of the child’s health history
4. Review of the dental history for the:
• Primary caregiver
• Any siblings
6. Caries risk assessment performed by the FDH trained dentist
7. Toothbrush prophylaxis (rubber cup prophylaxis if indicated due to stain, etc.)
8. Topical fluoride varnish application (on all erupted teeth)
9. Dental anticipatory guidance provided to the parent/guardian:
• Oral hygiene instructions
• Nutritional guidance
• Oral developmental milestones for the child
10. Establishment of a dental recall schedule
11. Any necessary referral to dental specialists
• All incomplete required procedures and the reason that they were not completed with explanations why
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.
Is there more than one possible code for the fluoride varnish?
There is no alternative. All fluoride varnish applications must be coded using CDT Code D1206.
Multiple Restorations on the Same Tooth
Patient presents with braces, radiographs acquired by the orthodontist, and evidence of poor oral hygiene. Radiographs show dark triangles just below the contact between nearly every posterior tooth, evidence of incipient decay. Immediate treatment was fluoride varnish application to teeth that may be conserved, and the following composite resin restorations – #14, separate MO and DO; #19, an MOD and a buccal pit restoration.
How would you code for the procedures on this visit?
Since fluoride varnish was applied, the appropriate code to use would be:
D1206 topical application of fluoride varnish
D2392 resin-based composite – two surface, posterior
Reported twice (MO and DO)
Why should a dentist code this scenario as two separate restorations when insurance companies for the most part combine the two restorations into a three or four surface restoration?
CDT is the governing factor in coding. You must code for what you do no matter how the claim is reimbursed.
To simplify the explanation: if the surfaces do not touch (such as the MO and DO), they must be billed separately.
Note: The CDT manual contains charts that describe in detail how to differentiate single and multiple surface restorations on both anterior and posterior teeth.
D2393 resin-based composite – three surface, posterior
D2391 resin-based composite – one surface, posterior
Dental plans may have clauses that restrict coverage on the same surface twice on the same date of service, and an alternate benefit provision may be applied. For example, payers often downcode separate restorations by recoding them as a single multiple surface restoration. Nevertheless, when individual restorations on the same teeth are done, they should be reported separately. Remember, “Code for what you do.”
Here is another example of a dental benefit plan language that limits or excludes coverage:
When multiple restorations involving the proximal and occlusal surfaces of the same tooth are requested or performed, the allowance is limited to that of a multi-surface restoration. Any fee charged in excess of the allowance for the multi-surface restoration by the same dentist/dental office is disallowed. A separate benefit may be allowed for a non-contiguous restoration on the buccal or lingual surface(s) of the same tooth.
You may also encounter the following limiting language in your participating provider contract:
Limit of One Restoration per Surface: Payment is made for one restoration in each tooth surface irrespective of the number or combination of restorations placed. A separate charge may not be made to the patient by a participating dentist.