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Change Makes Sense – Part I
By Marianne Harper

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 and generalized.

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 benefit payments.

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.

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