Coverage for Caries Risk Assessment Codes

An audience member asked: I was wondering if you can give me info on the D0601,602, and 603 codes for caries risk? I am wondering when to use them and if insurance is covering them? How much to charge?

Patti responded:

On the picture here notice, I have the word modifier in red. That is not a term used in the CDT, that is a word I use. In medical coding, modifier codes are well known. They are codes that support the necessity of other treatment. That is probably the best way to consider these CDT codes. They support other treatment.

What I am saying is there may not be coverage under those specific codes yet they support the dental-medical necessity for others. Fees should be based on the individual cost of doing business of practice and reasonable profit. Just because there is code that doesn’t necessarily mean there is a fee. For example, the D1330 should be used for oral hygiene instructions; whether an office chooses to charge for that treatment is a different matter.

Codes have 3 important functions:

  • 3rd party reimbursement
  • HIPAA said CDT is the standard code set for electronic health records and therefore must be correctly used in our charts
  • Metrics

Again, let me give an example of the metrics part. Many practices perform anti-bacterial irrigation as a standard part of the perio protocol. In the past, there was no CDT code. It could be submitted under D4999 unspecified perio treatment, by report. The ‘by report’ part means there must be a narrative so it was reported as irrigation. In 2013, the benefit carriers themselves asked the code committee for a new code for irrigation. Part of their reasoning was because it had been submitted under D4999 more than 500,000 time sin 2012 alone. How we code affects the future of coding.

Further there was a recent research study that published in JADA in Sept. 2018  on Assessing the validity of existing dental sealant quality measures . In their conclusion, it stated: Both the DQA and OHA measures, which rely mainly on Current Dental Terminology procedure codes, led to underestimation of the care delivered from a practice perspective. Future sealant quality measures should exclude patients whose teeth cannot be sealed.

Bottom line, using a code is important for more than reimbursement only.

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