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Coding Advocacy: A Look Behind the Scenes

Feb cover webAn important but overlooked component of AAE advocacy on behalf of members relates to the ADA Code on Dental Procedures and Nomenclature (CDT). AAE members frequently call for assistance with coding a claim or understanding why a claim wasn't paid by a dental plan. Member frustration stems from the fact that they performed a service or procedure reflected in the CDT code and are not reimbursed by the dental plan.

The AAE's Practice Affairs Committee is responsible for AAE advocacy on CDT as well as our advocacy with insurers. We sat down with PAC member and AAE's representative to the ADA Code Maintenance Committee, Dr. Kenneth B. Wiltbank, to find out more about what goes on behind the scenes.

AAE: Hi, Dr. Wiltbank, thanks for talking with us about dental coding and insurance. First of all, what is CDT?

Dr. Wiltbank: CDT is sometimes referred to as "the language of reimbursement." One use of the CDT is the processing of claims submissions. HIPAA requires that dental claims be submitted using CDT codes. Medical claims use a different system.

However, CDT's purpose is broad and not reimbursement-based: It is to provide uniformity, consistency and specificity in accurately reporting and documenting dental treatment and do so in a manner that can be understood by a computer without human intervention.

Each CDT code includes a five-digit alphanumeric code and a "nomenclature," which describes the service or procedure. For example, D3410, apicoectomy- anterior. Many codes also include a "descriptor" which provides additional information on use of the code. In the case of D3410, the descriptor is, "for surgery on root of anterior tooth; does not include placement of retrograde filling material."

AAE: How is the code on dental procedures and nomenclature managed and then maintained?

KW: The ADA Code Maintenance Committee meets annually to consider proposed changes. Since 2000, the AAE and each of the dental specialties have had a voting seat on the CMC. The CMC also includes representatives from third party payers (insurers/government) and ADEA.

Any person or organization can propose a code change. Approval requires a majority vote of the CMC. Code change requests should be based on the need to accurately document procedures performed and refer to a procedure, not a specific trade name, technique or instrumentation. They also should be concise, and requests pertaining to newly developed procedures should include documentation of clinical efficacy.

AAE: Let's take a closer look at the case history of the regenerative endo code. Give us an example of the AAE's advocacy for code changes.

In 2010 the AAE successfully advocated for a code revision to encompass pulpal regeneration. Dr. Bill Powell, a long-time member of the PAC, laid the groundwork to make the case for a revisions and it was discussed at my first CMC meeting.

Typically, codes are not approved on the first submission, but this time was different. The AAE arranged for Dr. Ken Hargreaves to testify on the science and clinical application of regenerative endodontics. It won't come as a surprise that Dr. Hargreaves' presentation was powerful. But that wasn't the end of the discussion.

There was pushback on whether a standalone code was warranted. There is a lot of strategy and relationship building involved. Dr. Powell was asked to come up with an alternative that would satisfy these concerns, including concerns of third party payers.
Dr. Powell proposed a compromise which was to add pulpal regeneration to codes D3352 and D3353, (apexification, revascularization) and add a new D3354. This was a major advocacy win for the AAE. Three years later, the AAE submitted a request for a standalone category and codes for regeneration, (D3355, D3356, D3357) and they passed easily.

AAE: If there is a code, why won't dental plans pay?

KW: If a procedure does not have a code, it is almost guaranteed that it will not be paid. Also, plans often deny D3999 (unspecified endodontic procedure, by report). The existence of a code recognizes the procedure and provides a means for documentation. So, it is essentially a prerequisite to being considered for payment.

The regeneration codes are a case in point. We know that some insurers pay and others do not. Some consider regenerative endodontics "experimental." All of this is within their rights to determine as long as it is consistent with their documented payment policy. We also know that practices that perform regendo more frequently have had some success in reversing these decisions on a case-by-case basis.

AAE: What has your experience been in meetings with dental directors of plans?

KW: When considering paying for new procedures or new technology, one thing the plans has to consider is the cost benefit from the standpoint of their customers (employers). With regeneration, I think part of the issue is that they still have not received a large number of claims. One of our jobs is to keep them in the loop about new developments in endodontics.

Obtaining a code is an important step in moving the needle with dental plans about advances in endodontics. In the long run, it will be the continued work of the AAE and the Foundation for Endodontics in advancing the specialty that will build the business case for reimbursement.

Additional Resources

The AAE's Guide to Claims and Coding Submission provides answers to the most frequently asked questions about proper coding.