D9000 – D9999 Adjunctive General Services
By Patti DiGangi, R.D.H., B.S.
Introduction
“Adjunctive” refers to any treatment or service that is provided in conjunction with another to increase the first treatment’s efficacy. In other words, adjunctive is a secondary treatment in addition to the primary therapy.
The Adjunctive General Services category is often searched when an appropriate code can’t be found in any of the 11 other CDT Code sections. This section differs from all the others in that there are codes for non-clinical and other services that don’t quite fit elsewhere. Many of the codes are for care that happens outside of the mouth or the practice setting. These procedure codes recognize nature of the support needed to complete other procedures.
Anesthesia: A patient’s level of consciousness is determined by the patient’s response to the drugs, not the route of the anesthetic agent administration. State dental boards regulate the use of anesthesia techniques. The ADA House of Delegates adopted and has published anesthesia policy and guidelines, which are available at ADA.org/en/member-center/oral-health-topics/anesthesia-and-sedation#addl.
Consultation: In a dental setting, a diagnostic service provided by a dentist where the dentist, patient, or other parties (e.g., another dentist, physician, or legal guardian) discuss the patient’s dental needs and proposed treatment modalities.
Medicament: Substance or combination of substances intended to be pharmacologically active, specially prepared to be prescribed, dispensed or administered by authorized personnel to prevent or treat diseases in humans or animals.
Microabrasion: Mechanical removal of a small amount of tooth structure to eliminate superficial enamel discoloration defects.
Palliative: Action that relieves pain but is not curative.
Parenteral: A technique of administration in which the drug bypasses the gastrointestinal (GI) tract. Examples of parenteral administration may include intramuscular (IM), intravenous (IV), intranasal (IN), submucosal (SM), subcutaneous (SC) or intraosseous (IO).
Teledentisty, Asynchronous: Also known as “store-and-forward,” involves transmission of recorded health information to a dentist, who uses the information to evaluate a patient’s condition or render a service outside of a real-time or live interaction. Such transmitted information includes radiographs, photographs, video, digital impressions and photomicrographs of patients. Transmission is through a secure electronic communications system.
Teledentistry, Synchronous: Also referred to as live video or real-time, synchronous teledentistry involves live, two-way interaction between a person (patient, caregiver, or provider) and a dentist using audiovisual telecommunications technology.
Teledentistry
CDT 2018 marks the first time teledentistry codes have been added. Teledentistry is the application of a broad variety of technologies and tactics to deliver virtual medical, health and educational services, commonly referred to as telehealth, to dental care. In dentistry it involves the exchange of information from one site to another via electronic communications. Patient outcomes can be similar to visiting a brick and mortar dental office.
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.
Previous submissions for teledentistry codes had been declined by the Code Maintenance Committee with the opinion that teledentistry is not a procedure but rather a place of service. Over time and with additional information, such as the ADA’s Comprehensive Policy Statement on Teledentistry that stated the provision of services using teledentistry technologies needs to be properly documented, created the need for unique CDT codes.
Using technology, dental professionals can screen, record, triage, diagnose and order care to be performed remotely. For teledentistry, the tipping point has been reached – it is here to stay. A complex technology solution, made easy to utilize is increasing access to care while increasing practice revenues.
Sedation/Anesthesia
The following four CDT 2018 changes illustrate how the code set evolves to enable procedure reporting at an appropriate level of detail. Two new entries for the “first 15 minutes” reflects the initial administration of the anesthetic agent. Revisions to the two existing entries enables documentation of subsequent 15-minute increments of anesthesia time.
Sedation/anesthesia code additions:
D9222 deep sedation/general anesthesia – first 15 minutes
D9239 intravenous moderate (conscious) sedation/analgesia – first 15 minutes
Sedation/anesthesia code revisions:
D9223 deep sedation/general anesthesia – each subsequent 15 minute increment
D9243 intravenous moderate (conscious) sedation/analgesia – each subsequent 15 minute increment
New entries for the “first 15 minutes” reflects the initial administration of the anesthetic agent. Revisions to the existing entries enables documentation of subsequent 15-minute increments of anesthesia time.
The CDT to ICD tables in Appendix 1 provide appropriate guidance on linkages between often used Adjunctive General Services procedure codes, and diagnosis codes.
ICD codes also aid in establishing “medical necessity,” which is especially pertinent when claims are submitted to medical benefit plans and Medicare.
Note: The ADA’s online Glossary of Dental Clinical and Administrative Terms defines “medically necessary care” as:
The reasonable and appropriate diagnosis, treatment, and follow-up care (including supplies, appliances and devices) as determined and prescribed by qualified, appropriate health care providers in treating any condition, illness, disease, injury, or birth developmental malformations. Care is medically necessary for the purpose of: controlling or eliminating infection, pain, and disease; and restoring facial configuration or function necessary for speech, swallowing or chewing.
“Medical necessity” is not static. The prudent approach is to anticipate that a claim for dental services will be filed against a patient’s medical benefit plan or Medicare, and determine and document the patient’s diagnosis at every visit. Even if there is no such claim filed, the patient’s dental record will be more robust by inclusion of codified diagnostic information.
CODING SCENARIO #1
Denture Cleaning
Patient presents with thermal sensitivity of teeth #22 and #27. She has a full upper denture and partial lower denture. The initial treatment plan is to clean the dentures and take a radiographic image of all remaining lower teeth. Upon viewing the images, the dentist sees no periapical pathology for teeth #22 and #27. Both have significant gingival recession with deep erosion at the gingival margin of #22. He performs desensitizing treatment for #27 and cervical resin for #22.
How do you code this care?
D0140 limited oral evaluation – problem focused
D0220 intraoral periapical first radiographic image
D0230 intraoral periapical each additional periapical image
This procedure is reported three times as this is the number of additional images.
D9910 application of desensitizing medicament
This procedure is reported for tooth #27.
D9911 application of desensitizing resin for cervical and/or root surface
This procedure is reported for tooth #22.
D9932 cleaning and inspection of complete denture, maxillary
D9935 cleaning and inspection of removable partial denture, mandibular
Extended Care Facility Call
A long-term patient is living in an assisted living facility close to your dental practice. Her daughter calls your office and says her mother is in pain but cannot travel to the office. The dentist arranges to see the patient at the assisted living facility. He finds a large sore under the patient’s denture. No care is rendered other than a discussion of comfort care and to monitor the sore which should go away within 14 days.
How would you code this care?
D9410 home/extended care facility call
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