04/30/2015

Health payers switch to new diagnostic codes this year

By Greg Alterton, CDA Dental Benefit Plan Specialist

Increasingly, dental plans are deferring to medical benefit carriers on certain dental procedures that can be claimed as medical procedures with patients’ medical plans. More and more, these medical plans are paying for not only surgical dental procedures, but some preventive dental services as well. In submitting claims to medical plans, dentists need to be aware of and prepare for the adoption of new medical diagnostic codes that will be in use beginning Oct. 1.

Diagnostic codes have been in use to describe patients’ illnesses and conditions for nearly 300 years. They were initially used to keep records and generate statistics on sicknesses, diseases, causes of death and health conditions within the population. They evolved to become the system to classify all health conditions needing treatment intervention. 

In dentistry, CDT codes are, of course, associated with treatment procedures. Diagnostic codes are a characterization of the reason for the treatment. On the medical side, treatment codes go hand-in-hand with diagnostic codes. In a sense, a care provider justifies the procedure through the proper use of the diagnostic code.

The shift from the International Classification of Diseases version nine (ICD-9) to ICD-10 is actually long overdue in the U.S. As part of HIPAA requirements, ICD-10 was mandated to replace the current ICD-9 on Oct. 1. It’s important to note that claims submitted on or before Sept. 30 will need to reference ICD-9. But failure to switch over to ICD-10 on Oct. 1 will result in medical claims being denied.

There are two types of ICD-10 codes: ICD-10-Procedure Code System, which is for use in hospital-based care, and ICD-10-Clinical Modification codes, which are for use in outpatient care and will be used mainly for in-office dental treatment.

The main reason for the change is that ICD-9 has reached its limitations. There are more than 14,000 codes within ICD-9. With the use of a new alphanumeric system, ICD-10 is able to accommodate 70,000 diagnostic designations for outpatient care, and another 72,000 for in-patient hospital care. 

While used mostly in medical claims and reporting, ICD-10 recognizes most conditions that require treatment by a dentist. Under the new alphanumeric code system, conditions that begin with the prefix “K” are diseases of the digestive system. Under this, conditions K00 through K14 are diseases of the oral cavity, salivary glands and jaw. For example, K02 refers to various conditions related to dental caries, specifically. 

ICD-9 also contains codes for designating oral health conditions needing treatment, but the descriptors in the ICD-10 codes are more detailed, providing greater specificity when identifying a condition in need of care.

As the ICD-10 codes haven’t left out dental conditions, the standard dental claim form hasn’t left out the possibility of using diagnostic codes. Looking at the ADA claim form, box 34a allows for logging of diagnostic codes. For the time being, dental plans are not requiring the use of diagnostic codes on claim forms (such codes are required on medical claim forms), but the dental claim form anticipates their use in the future. In fact, some state Medicaid programs are looking to require diagnostic codes for dental care. So, dentistry is not that far away from use of diagnostic codes on dental claim forms. 

Dentists most likely to be impacted immediately by the shift to ICD-10 are oral surgeons, dentists who treat temporomandibular disorders, facial pain or sleep apnea, oral pathologists, oral radiologists, pediatric specialists who treat patients in a hospital setting, and dentists who work in public health settings. 

If you believe you will need to use ICD-10 codes, there are some things you should be doing right now. Check with your billing service (if you have one), clearinghouse (if you use one) and practice management software vendor about how they intend to comply with the shift to ICD-10. Dental plans and clearinghouses should have the ability to allow you to test your software to assure that it can successfully include and transmit ICD-10 codes.

ICD-10 codes are adopted by the federal government and are available, free of charge, from the Centers for Medicare and Medicaid Services. Go to www.cms.gov/ICD10 for further information. Also, the codes themselves can be downloaded from cms.gov.



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