Questions and Answers
(Q&A)
These Q&A are brought to you by the Council on Dental Benefit Programs (CDBP) and add to what are in the current CDT manual. Q&A are here to assist dentist’s and practice staff determine the most appropriate procedure code to document the service provided, as well as better understand the claim form completion and adjudication processes.
Please note that; 1) this information is not part of the Code on Dental Procedures and Nomenclature (Code), and 2) dental benefit plan coverage limitations and exclusions, and where applicable the provisions of a participating provider agreement, affect third-party payer claim adjudication.
The latest Q&A follow. New information is frequently added, so please bookmark this page. Past Questions and Answers are available in the Q&A Archive | PDF file/325k  .
Coding
1. What is occlusal equilibration, and how would it be documented?
Occlusal equilibration, also known as occlusal adjustment, refers to the reshaping of the occlusal surfaces of teeth to create a harmonious contact relationship between the upper and lower teeth.
Coding:
D9951 occlusal adjustment – limited
May also be known as equilibration; reshaping the occlusal
surfaces of teeth to create harmonious contact relationships between the maxillary and mandibular teeth. Presently includes discing/odontoplasty/enamalplasty. Typically reported on a “per visit” basis. This should not be reported when the procedure only involves bite adjustment in the routine post-delivery care for a direct/indirect restoration or fixed/removable prosthodontics.
D9952 occlusal adjustment – complete
Occlusal adjustment may require several appointments of varying length, and sedation may be necessary to attain adequate relaxation of the musculature. Study casts mounted on an articulating instrument may be utilized for analysis of occlusal disharmony. It is designed to achieve functional relationships and masticatory efficiency in conjunction with restorative treatment, orthodontics, orthognathic surgery, or jaw trauma when indicated. Occlusal adjustment enhances the healing potential of tissues affected by lesions of occlusal trauma.
2. A patient is having porcelain veneers placed on teeth 6 through 11. The dentist is having the laboratory make a diagnostic wax-up. What is a diagnostic wax up and how would it be documented?
A diagnostic wax-up presents the patient with a natural-looking, three dimensional representation of the final case. Also, through the diagnostic wax –up, the dentist can obtain a visual understanding of tooth reduction requirements.
Coding:
D9950 occlusal analysis –mounted case
Includes, but is not limited to, facebow, interocclusal records tracings, and diagnostic wax-up; for diagnostic casts, see D0470
3. What is a flipper/stayplate and how would it be documented?
A flipper/stayplate is a temporary removable partial denture typically fabricated out of hard acrylic, the same material used to make a standard complete denture.
Coding:
D5820 Interim partial denture (maxillary)
Includes any necessary clasps or rests
D5821 interim partial denture (mandibular)
Includes any necessary clasps or rests
4. What is a torus/exostosis and how would removal be reported?
A torus/exostosis is a benign overgrowth of bone forming an elevation or protuberance of bone. They can form in the patient’s palate, lingual or lateral aspect of the mandible.
Coding:
D7471 removal of lateral exostosis (maxilla or mandible)
D7472 removal of torus palatinus
D7473 removal of torus mandibularis
Claim Form
In the past, our office has always used UR, UL, LR, and LL to indicate the area of the oral cavity. I have heard that these symbols are not being used any longer. Is this correct?
Yes, the Area of the Oral Cavity is now designated by a two-digit numeric code, which is a HIPAA standard. This code is placed in Item 25 of the current ADA paper claim form (2006 © American Dental Association). Completion instructions for this field, as published in the CDT manual, follow:
25. Area of Oral Cavity: Use of this field is conditional. Always report the area of the oral cavity unless one of the following conditions in Item #29 (Procedure Code) exists:
a. The procedure identified in #29 requires the identification of a tooth or a range of teeth.
b. The procedure identified in #29 incorporates a specific area of the oral cavity in its nomenclature (for example, D5110 complete denture – maxillary).
c. The procedure identified in #29 does not relate to any portion of the oral cavity (for example, D5914 auricular prosthesis, or D9220 deep sedation/general anesthesia – first 30 minutes).
Area of the oral cavity is designated by a two-digit code, selected from the following code list:
| |
| CODE |
AREA |
00 |
entire oral cavity |
01 |
maxillary arch |
02 |
upper right quadrant |
10 |
upper right quadrant |
20 |
upper left quadrant |
30 |
lower left quadrant |
40 |
lower right quadrant |
Adjudication
Sometimes how a payer adjudicates a claim appears inconsistent with the ADA’s message – “code for what you do.” For example:
A patient is missing teeth 3,4,12 and 13. The dentist’s treatment plan includes two- four unit fixed partial dentures. When the claim is adjudicated, the benefit contract makes an allowance equivalent to a removable bilateral partial denture. This is an example of a benefit contract containing a least expensive alternative treatment (LEAT) clause.
LEAT is a contractual limitation that will only allow benefits for the least expensive treatment when there are multiple treatment options for a specific condition. LEAT does not determine treatment, but does determine level of benefits available.
Please remember – dental benefit plan coverage limitation & exclusions, and where applicable the provisions of a participating provider agreement, affect third-party claim adjudication.
Contact Information
Telephone: ADA Members, please use the toll-free number on the back of your membership card; Direct dial, 312-440-2500
E-mail: dentalcode@ada.org |
