As we learn
more about the proven association between oral
health and overall body health and realize that
dental offices will need to be able to file medical
claims for their patients, I have some interesting
news to report. The CMS (Centers for Medicare
and Medical Services) and the NCHS (National Center
for Health Statistics), who are responsible for
publishing the ICD-9-CM (diagnosis code manual),
are recognizing this association and responding
appropriately to it. With the release of their
updated codes effective October 1, 2006, there
are seventy-four new codes and six revised codes
that are dentally related.
If you will recall from my article "Crack
the Code" in the March 2005 issue
of Dental Practice Report, The ICD-9-CM
codes are the diagnostic codes that are needed
for all medical claims. Medical insurance is diagnosis
driven and you must have at least one diagnosis
code to support the medical necessity of the claim.
Diagnosis codes are placed in box 21 of the CMS-1500
(medical) claim form.
The first eight of the new ICD-9-CM codes that
are of interest to dental practices are not truly
specific to dental. They are in the 300 level
codes and are comprised of codes for different
types of pain not already addressed by the codes
that are part of the code set.
The next group is in the 500 level of codes and
these are codes specifically used for dentally
related procedures. Codes that were deleted were
less specific than the new codes. The invalid
codes are 521.8, 523.0, 523.1, 523.3, 523.4, 528.0,
784.9, 995.2, and V18.5. Most of these were gingival
and periodontal codes. As of October 1, 2006,
we now have gingivitis and periodontal codes grouped
by acute, aggressive, and chronic as well as by
areas of the mouth such as unspecified, localized
There are also codes in the 500 level that deal
with dental restorative conditions. There are
new codes for unsatisfactory restorations, open
margins, overhanging restorations, fractured restorations,
allergies to restorative materials, and poor aesthetics
of existing restorations.
Some endodontic conditions are also addressed
in the 500 level. There are codes for perforation
of root canal space, endodontic overfill, endodontic
underfill, and other periradicular pathology associated
with previous endodontic treatment.
The remaining four new codes in the 500 level
deal with Stomatitis and Mucositis.
There are three new codes for dental procedures
in the 700 level codes. One of the codes can be
used for major osseous defects, another is a generalized
pain code, and the last is for other symptoms
involving head and neck.
The 900 level has three new codes that can apply
to dental procedures and they deal with drug allergies
and adverse effects of a drug or medicinal substance.
The last updates are in the V codes. V codes
are used on medical claims to classify patients
who are not currently sick but who encounter health
services. These codes are also listed in box 21
but are entered after the diagnosis codes. There
are only two updated codes in this group and they
deal with family history of other digestive disorders
and encounters for removal of sutures.
It is very important that, as of October 1, 2006,
we do not use the invalid codes. Insurance carriers
do not offer grace periods on the deleted codes.
Claims will deny and this will cause delays in
We need to keep in mind that, although great
strides have been made in incorporating dentally
related codes to this code set, it does not mean
that we will be able to successfully file any
dental procedure that appears to be covered by
these codes. Insurance carriers will need to accept
these codes into their plans for that to happen.
Don’t let that stop you from filing medical
claims, as long as the procedures are medically
necessary. The more the insurance carriers see
these dentally related claims cross their desks
and the more we get our patients to complain to
their insurance plan administrators, the more
likely we are to be successful in obtaining benefits.
Remember this – just because there is a
code doesn’t mean that it is covered. We
still have a long way to go. So be persistent,
file those claims, and inform your patients that
they should be involved, too.