Devdent Basics Course

Medical Billing for Dentistry | Devdent

Devdent

Basics Course

Workbook

Laurie Owens, CPC, CPB

This presentation is for discussion and education purpose only.

It is not intended to offer or to be used as legal advice. All codes are owned by the ADA and AMA.

Laurie Owens, CPC, CPB Laurie Owens, is the Director of Medical Billing Education for Devdent. She brings over a decade of experience educating dental practices on billing medical insurance and the techniques to get claims paid. Laurie believes that patients should be able to utilize their medical insurance for procedures due to oral systemic conditions. Through on-site training, medical billing courses, Seattle Study Club lectures, AADOM (American Association of Dental Office Managers) and follow-up consulting, Laurie has assisted dental practices in successfully billing medical insurance to collect benefits that would have otherwise been unclaimed. Her training on medical billing has increased practice revenue and patient satisfaction.

Outline:

Session 1: • Chapter 1 – The Who, What, Why, & How Who can bill medical What you need to know Why this is important for dentistry How do we get it done

Session 2: • Chapter 2 – Procedures & Diagnosis What to look for with conditions & co-morbidities

Session 3: • Chapter 3 – SOAP Documentation What does SOAP mean What to say What not to say

Session 4: • Chapter 4 – Fraud & Implementation Stark Laws False Claims Act Roles Health History Who does what

Session 1

Who Can Bill Medical Insurance?

SEC. 2706. NONDISCRIMINATION IN HEALTH CARE. The Federal health care law states the following: “(a) PROVIDERS. A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law.”

Any licensed professional, DDS, DMD, MD or DO, can perform any medical procedure that falls under the scope of their license – state and federal guidelines apply.

• A Dentist performing a bone graft bills the exact same procedure code as a plastic surgeon performing a bone graft.

• An oral surgeon uses the exact same extraction code as a general dentist.

We all use ONE set of codes

Affordable Care Act: section 2590.715-2719A

A plan or issuer subject to the requirements of this paragraph (b) must provide coverage for emergency services in the following manner –

(i) Without the need for any prior authorization determination, even if the emergency services are provided on an out-of-network basis. (ii) Without regard to whether the health care provider furnishing the emergency services is a participating network provider with respect to the services. (iii) If the emergency services are provided out of network, without imposing any administrative requirement or limitation on coverage that is more restrictive than the requirements or limitations that apply to emergency services received from in-network providers. (iv) If the emergency services are provided out of network, by complying with the cost- sharing requirements of paragraph (b)(3) of this section; and (v) Without regard to any other term or condition of the coverage, other than –

(A) The exclusion of or coordination of benefits; (B) An affiliation or waiting period permitted under part 7 of ERISA, part of title XXVII of the PHS Act, or chapter 100 of the Internal Revenue Code; (C) Applicable cost sharing.

Procedures: Procedure codes - CPT and HCPCS (hick picks). 5 Digit Alpha Numeric codes Miscellaneous codes 41899 are to be used for extractions along with a qualifier

CPT is an acronym for Current Procedural Terminology. The codes are published by the American Medical Association (AMA) much like our CDT codes are published by the American Dental Association (ADA). The purpose of the coding system is to provide uniform language that accurately describes medical, surgical, and diagnostic services.

Dental Related CPT Codes - This is only a partial list

41820 – Gingivectomy (D4210, D4211, D4212, D4230, D4231, D4240, D4241, D7971) 41800 – Drainage of Abscess (D7510, D7511, D7520, D7521) 41805 – Removal of Foreign Body (D4341, D4342, D4355, D7530) 41823/41830 – Excision of Osseous Tuberosities (D4260, D4261) 41870 – Periodontal Mucosal Grafting (D4270, D4273, D4275, D4274) 41874 – Alveoplasty (each quad) (D7310, D7311, D7320, D7321) 21031 – Excision of Tori Mandible (D7471, D7472, D7473, D7972) 21032 – Excision of Tori Maxilla (D7471, D7472, D7473) 40806 – Labial Frenectomy (D7960) 41010 – Lingual Frenectomy (D7960, D7963) 70486 – CBCT/Cone Beam (D0322, D0360, D0364-68, D0380-84) 70320 – FMX (D0210) 70355 – Pano (D0330) 70300 – PAX (D0210, D0220, D0230 99152 – Moderate (IV) Sedation (first 15 minutes) (D9220 – first 30 minutes) 21210(5) – Bone graft maxillary/mandible (D4263, D6104, D7951, D7953) 21248(9) – Implant (including abutment) (D6010, D6057, D6058) 0232T – PRP 0481T – PRF

Modifiers - This is only a partial list

• Modifiers add additional information about a procedure, CPT or HCPCS • 4 modifiers per procedure can be used. Those indicated with * must be listed first.

22 – Increased Procedural Service 25- Separate E&M Service on Same Day of a Procedure *26- Professional Component *TC- Technical Component 33 – Preventative Service 50- Bilateral Procedure 51- Multiple Procedures 52- Reduced Services 54- Surgical Care Only

55- Postoperative Management Only 56- Preoperative Management Only 76- Repeat Procedure by Same Physician 77- Repeat Procedure by Another Physician NU- New Durable Medical Equipment Purchase KX - Requirements specified in the medical policy have been met

Qualifiers - This is only a partial list

• Qualifiers add additional information about a procedure, CPT or HCPCS • There is no limit on the number of qualifiers, but each require additional information.

JO- Dentistry Designation System for Tooth and Areas of the Oral Cavity

00 Entire oral cavity 10 Upper right quadrant 01 Maxillary arch 20 Upper left quadrant 02 Mandibular arch 30 Lower left quadrant 40 Lower right quadrant

JP- Universal/National Tooth Designation System 1 - 32 Permanent dentition 51 - 82 Permanent supernumerary dentition A - T Primary dentition AS - TS Primary supernumerary dentition

ZZ- Narrative description of unspecified code

This is how a modifier and qualifier can be used on a paper claim form:

Diagnosis Codes:

• Diagnosis codes - ICD-10 Codes. Updated annually on 10/1, effective 1/1 -12/31 for the following year. Approximately 77,000 codes. • ICD-10 Codes are designed to get more specific with length. 3-7 digits, always in this format: S42.001A - Fracture of unspecified part of right clavicle, initial encounter for closed fracture • Maximum of 12 ICD-10 Codes per claim, 4 ICD-10 Codes per procedure. Always list the primary diagnosis code, i.e. diagnosis, condition, problem, or other reason for visit first, then list codes for any supporting or co-existing conditions. • External cause codes W21.11XD, struck by baseball bat, subsequent encounter is always last, and are required for any trauma or injury.

Procedure Codes

Dental Related ICD-10 Codes - This is only a partial list

R06.83 – Snoring R68.84 – Jaw Pain R40.0 – Daytime Tiredness M27.8 – Tori R06.5 – Mouth Breathing M26.19 – Retrognathia K14.8 – Enlarged Tongue M26.53 – Deviation in Opening or Closing G89.11 – Acute Pain Due to Trauma M26.601 – TMD Right Joint K08.21 – Minimal Atrophy of Mandible M26.602 – TMD Left Joint K08.22 – Moderate Atrophy of Mandible M26.603 – TMD Bilateral Joint K08.23 – Severe Atrophy of Mandible K12.1 – Cellulitis or Abscess of the Mouth K05.211 – Aggressive Perio, Local, Slight Z91.841 – Screening for Caries – low risk Z91.842 – Screening for Caries – moderate risk Z91.843 – Screening for Caries – high risk

Why is this important for dentistry?

• Increase case acceptance by decreasing patient portion • Leave dental benefits for future dental procedures • Get paid for what you are doing • Medical has no maximums or frequency limitations • Separate your practice from others

How Imagn Billing from Devdent is Different:

Imagn Billing from Devdent is different. Here are two important things that separate us from other billing companies:

1. Our medical billing software was created for medical billing in dentistry. What that means is that you can use your dental codes and we will tell you how it cross-codes into medical. 2. Our medical billers do all the follow-up on your claims. This means that when your patient comes in for an appointment and says, “What is the status of my medical claim?” You can log into the cloud-based software and see when insurance was called, what transpired, and when they will be contacting them again.

Imagn Billing by Devdent:

Imagn Billing features dental-to-medical cross coding when adding procedure codes, Medical Billing for Dentistry | Devdent

Add supporting information such as referrals, lab charges, documents and more before submitting your claim to Imagn Billers.

Receive frequent, detailed case updates from Imagn Billing from case submission to decision.

Send and receive documents inside Imagn Billing.

Communicate directly with Imagn Billers by using the Messages tab inside each case.

Verification of Benefits:

Receive a breakdown of medical insurance benefits including:

• Representative name • Effective dates • Benefit renewal dates • Gap exception information • In and out of network benefits

24-hour weekday turn around

Receive a breakdown of medical insurance benefits including:

• Individual and family deductible amounts

• Individual and family out of pocket maximums • Office visit copay amounts

Per -procedure code breakdown: • Is the procedure a covered benefit? • In and out of network coverage amounts • ICD -10 code specific coverage • Preauthorization requirements • Code specific information obtained such as CPAP trial details, appliance replacement policies and more • Reference numbers, required fax numbers and additional information regarding the policy will be in the notes section • If a faxed VOB is obtained, it will be attached under eligibility verification form Verification on Availity:

Remember, without a phone call, you will not get specific code required information. This will be basic eligibility, deductible, and possible reimbursement.

Availity Claim Filing:

PDF Fillable Paper Claim (CMS-1500):

There are only a few providers that will accept paper claim forms. Make sure that you are not duplicating efforts by contacting the provider to make sure they will accept a paper claim. Most BCBS offices will not accept a paper claim. You will need to purchase the claim form from Amazon, Office Depot, or Staples.

Session 2 -

EOB for Crowns:

EOB for Endo:

Implant EOB:

Can you prove medical necessity?

Accidents need an activity code as secondary. Primary should be what happened because of the trauma, i.e. dislocated tooth, fracture of tooth.

EXAMPLE: Patient fell off the toilet after fainting and hit his mouth on the tub in the fall. The first visit (exam) to your office and ALL appointments to correct what the injury caused would be:

W18.12XA - Fall from or off toilet with subsequent striking against object, initial encounter R55 - Syncope, collapse, fainting

Follow-up visits to fix prior work like, remove appliance, integration of implant, etc:

W18.12XD - Fall from or off toilet with subsequent striking against object, subsequent encounter R55 - Syncope, collapse, fainting

If you did a splint a year ago and it has now failed it would be:

W18.12XS - Fall from or off toilet with subsequent striking against object, sequela R55 - Syncope, collapse, fainting

Accidents need to have the story told in reverse. Primary diagnosis code will be what you needed to fix (partial loss of teeth due to trauma). Second diagnosis code would be what the result of the trauma (fracture of tooth, dislocation of tooth etc.). Third would be what the trauma was or what happened to cause the result of necessary treatment (fall from toilet with subsequent striking against and object). Fourth and last code could be a defining activity, location, or pertinent information (fainting, playground, yard).

When we code accidents, the ending letter of the code tells medical insurance at what stage of the trauma you are treating:

ü The code ending with an A means active. You will use the ending letter A for all trauma cases that mean treatment is actively being corrected. ü The code ending with a D means this is a subsequent visit. You will use the letter D for follow-up, removal of sutures past the 90-day global period, for adjustments outside of the global period, removal of a fixed appliance, etc. ü The code ending with an S means the sequela (the consequence of a previous injury) and again as many as needed to get your patient back to where they should have been.

Session 3 -

S – Subjective:

Synopsis of the Subjective information: The subjective section should only include what the patient reports and should include SYMPTOMS. Medical conditions in this section are not necessarily verified by a physician. Chief complaint and medical history are the most important things to collect. If you do not find anything to add to the ROS (review of systems), you will just leave it blank. Leaving 1 of these 5 sections incomplete does not necessarily make your note incomplete.

There are 5 key components with subjective information:

1. Chief Complaint (CC) 2. History of Present Illness (HPI) 3. Medical and Social History 4. Review of Systems (ROS) 5. Current Medications and Allergies

1 - Chief complaint:

o The chief complaint is the reason for the visit o Symptom, condition, previous diagnosis, or short statement that describes why the patient is presenting today o Patient’s may have more than one chief complaint o It is the providers responsibility to determine which one is the primary or most relevant

2 - Suggested discovery questions for HPI (history of present illness):

o Onset: When did the CC begin? o Location: Where is the CC located? o Duration: How long has the CC been going on for? o Characterization: How does the pt describe the CC? o Alleviating or Aggravating factors: What makes the CC better? Worse? o Radiation: Does the CC move or stay in one location? o Temporal factor: Is the CC worse or better at a certain time of the day? o Severity: Using a scale of 1 to 10, 1 being the least, 10 being the worst, how does the pt rate their CC?

Example of subjective chief complaint and HPI documentation: CC: Severe jaw pain HPI: Sally, a 34-year-old female patient presenting with a chief complaint of severe jaw pain. She reports pain is a 5 (on a scale of 10) on the lower right area of the jaw. It has gotten worse over the last 3 days. She has taken Motrin and feels very little relief. The pain is severe enough that she missed work today and it’s kept her from sleeping.

Subjective Tip: When asking questions, try to avoid questions with "yes" or "no" answers or questions that could lead them to an answer, such as "that hurt didn't it".

3 - Medical and Social Review:

o Here you will list all health conditions the patient reports. o Many of these will be irrelevant to the necessary procedure, but it’s part of a complete note.

Example: MHX: Hypertension, Headaches, and Heart Disease.

4 - Review of Systems (ROS):

o System-based list of questions that help uncover symptoms not otherwise mentioned o Height, Weight, Blood Pressure o Questions like, “Are you currently under the care of a physician? If yes, why?”

Example: ROS: Height 5’ 6” Weight 150 lbs. BMI 28. BP 135/78 with meds. Patient indicated she has experienced a recent weight gain. She is under the care of a physician for hypertension and sees a cardiologist for her heart disease. She also reported that she’s started to experience acid reflux on a regular basis.

5 - Current Medications and Allergies:

o Can be listed under Subjective or Objective sections o Any medication documented should include Medication name Dose Frequency o List any known allergies or NKDA

Example: Motrin 600 mg orally every 4 to 6 hours for 3 days

Subjective Tip: It’s not uncommon for a patient to report a medication, that brings to light an undisclosed medical condition. If a patient is taking OTC acid reflux meds, but didn’t list acid reflux as a medical condition, this can then be added to the ROS.

O – Objective:

Synopsis of Objective Information:

The objective section Includes the clinical findings, observations, tests or evaluation results. This may include extra oral exam, intra oral exam, radiographic findings, perio chart results, screening results, tooth sensitivity found through percussion, biopsy results or vitality test results. The details in this section should be limited to things that can be diagnosed by the dentist.

Intra-Oral Exam: Extra-Oral Exam:

§ Tongue, Tonsil or Mallampati Grade § Muscles Tender to Palpation § Swelling or Discoloration § TMJ - Popping, Clicking, Pain § Lesion § Swelling or Discoloration § Infection § Neck Circumference § Laceration or Bleeding § Posture § Caries or Fractures § Tooth Wear or Abfractions § Existing Dental Work § Hard & Soft Palate § Classification of Occlusion § Deflection or Deviation § Range of Motion (ROM) § Missing Teeth

Radiographic Findings (include the image type that is being reviewed):

o Atrophy - include location and severity. i.e. CBCT was taken and shows moderate bone atrophy of the maxilla in the right quadrant.

o Caries - Include location and severity. i.e. BWX was taken and shows #4 has caries through enamel into the pulp chamber, showing pulpitis, this is causing pain and extreme sensitivity.

o Infection - include location and severity. i.e. PA was taken and shows #3 has a large abscess causing atrophy of the surrounding area. Infection is significant and causing pain.

o Missing Teeth - include location and classification of missing tooth. CBCT was taken and shows #2 is missing, partial loss class II. Moderate bone atrophy is present.

o Tooth Specific - Pano was taken and shows #1, 16, 17 and 32 are completely impacted in the bone. This is causing pain and showing signs of infection around #32. #17 is also starting to deteriorate the structure of nearby teeth.

Objective Tip: Don’t confuse symptoms, which are what the patient reports in the subjective section, with signs, which belong in the objective section. An example of this is a patient stating she has “jaw pain,” which is a symptom, which belongs under the subjective section. Versus “tooth tenderness to palpation,” an objective sign which should be documented under the objective section.

A – Assessment:

Synopsis of Assessment:

This section is where you document the providers findings, as they combined the “subjective” and “objective” evidence to arrive at a diagnosis. This is where you list the medical necessity, the consequences if left untreated and prognosis with treatment. You will also list the actual diagnosis, in order of importance. When possible include the ICD-10 code with description.

Example of Assessment: A: With the active infection and the underlying heart condition, failure to treat this infection could be very dangerous. The atrophy of the bone is already moderate, compromising form and function. Without the implant placement, atrophy will continue and could eventually affect the sinus cavity. The impacted teeth are a result of a development issue and will not self-correct. Extraction will be required to remove the impacted teeth which is necessary to prevent further infection. This surgical treatment is medically necessary and failure to treat could result in serious complications. With treatment, infection will be removed, atrophy will be slowed, function will be restored, and pain will be eliminated.

K08.432 Partial Loss of Tooth Class II K08.25 Moderate Atrophy of the Maxilla K12.2 Abscess K01.1 Impacted Teeth R68.84 Jaw Pain

P – Plan:

Synopsis for Plan:

The plan section lists the provider’s plan for treatment, testing or referral of the patient. This can be procedure codes, as well as any additional treatment or testing needs.

o CPT Codes – Treatment Plan o Testing - which tests are needed and why o Medications Prescribed o Specialist Referrals o Patient Education or Counseling

Example of Plan:

Tx Plan: #3 - 21248 Implant, #3 - 21210 Bone Graft, Prescribed Amoxicillin 500 mg #28 QID x7 days until gone. RTC, approximately 3 months post-surgery, for CBCT to confirm complete osteointegration in preparation for abutment and crown.

Plan Tip: Another provider should be able to read the plan and pick up where you left off. Use the words medically necessary, serious complications, infection, form and function, development issue, and surgery whenever possible.

The medical record (SOAP note) must contain enough documentation of the patient’s condition to substantiate the medical necessity for any procedure. If the information in the medical record does not adequately support the medical necessity for the procedure or service, the dentist may be liable for the dollar amount of the claim. Supporting documentation must be on file for at least 7 years or must follow state requirements.

Chart note:

S: 23-year-old male presents stating, “my lower left jaw in the back has been sore for the past few days.”

History of present illness (HPI): Pt relates that there has been swelling for the past 3 days, previously asymptomatic.

Medical history: medical conditions – Asthma; Medications – Albuterol; Allergies – seasonal pollen; past sx – gall bladder removal 2009; Social history: tobacco and alcohol use daily.

O: Vitals: BP - 123/75 HR - 67 HbA1c - 5.0

Clinical exam: CBCT taken and reviewed today.

Extra oral – (Asymmetry, swelling, erythema, pain, paresthesia, infection, tmj) No asymmetry or swelling. Pt points to 17 for pain extra orally.

Intraoral – (Swelling, exudate, erythema, hemorrhage, mobility, occlusion, pain, biotype, hard tissue, infection) 16 has supra erupted and occluding on pericoronal tissue of 17. 17 has partially erupted, has erythematous tissue, no hemorrhage, slight exudate, fetid odor, pain to palpation pericoronal tissue 17.

A: Asthmatic – exercised induced Smoker (1 pack per day) 16 supra erupted and occluding on opposing gingiva 17 pericoronitis

P: Removed 16 today with operculectomy, consent signed.

Prescribed: Amox 500mg 1 BID x 10 days, Motrin 800mg Q 4-6 h x 4 days, Tylenol 3 Q 4-6 h x 4 days as needed for pain.

Healing evaluation scheduled for 10.25.19

Session 4 -

Resources: www.devdent.com

This website offers many helpful features, including searching for descriptions of codes, assessing narratives for codable items as well as scrubbing claims - www.findacode.com. www.fairhealthconsumer.org – Fair Health Consumer www.icd10data.com (free diagnosis codes) www.icdlist.com (free diagnosis codes) www.nucc.org (medical claim form definitions/help) www.mdcodewizard.com (free download of a writable pdf of the medical claim form) (printer settings must be actual size and portrait…purchase CMS 1500 forms from Amazon, you cannot use a form that is not the specific red color ink) www.availity.com (free site to see medical benefits and file medical claims) www.navinet.net (free site to see medical benefits and file medical claims) www.onehealthport.com (free site to see medical benefits and file medical claims) www.healthid.optum.com (free site to see medical benefits and file medical claims)

Kaiser: So California: www.providers.kaiserpermanente.org/socal Georgia: www.providers.kaiserpermanente.org/ga Washington: www.providers.kaiserpermanente.org/wa Colorado: www.providers.kaiserpermanente.org/cod Mid-Atlantic: www.providers.kaiserpermanente.org/mas Hawaii: www.providers.kaiserpermanente.org/hi www.aimspecialtyhealth.com (online for CBCT preauthorization) www.radmd.com (online for CBCT preauthorization) www.evicore.com (online for CBCT preauthorization) www.previser.com (free risk assessment) www.npinumberlookup.org (look up medical doctor npi #)

Sample of an Encounter Form:

SOAP note example for FM reconstruction:

Patient contacted the office with concern for mandible arch. They state concerns of difficulty masticating and is suffering from poor nutrition with current loose prosthetic denture. Patient previously lost complete arch due to severe periodontal disease and infection/swelling along with moderate atrophy. Patient expressed concern to have maxilla reconstructed due to continued atrophy.

In 2013, he was seen in our office and had maxillary atrophy, partial loss of 6 teeth in the maxilla and severe periodontitis. Over the course of 2013-2014, they were treated for severe periodontal disease, swelling, and infection of the maxilla and treated with amoxicillin and teeth removal. Two other dental offices report history of care. RMH. LOE.

Medical history – no medication and NKDA. Salivary PH testing results taken today are 7.0- 7.5. Patient reports previous smoking history for 23 years ad has quit 1 year ago. Moderate to severe maxillary atrophy noted. Complete tooth loss in the maxillary arch along with atrophy and Erythema present.

Reviewed previous radiographs to assess maxillary atrophy. Will need to take a full CBCT to measure bone levels at a future date when the patient has more time to discuss full treatment plan. Current denture is unstable and non-retentive. Prosthetic contributes that he experiences a loss of taste, tactical sensation, and creates food aversion contributing to the patient’s complaint of poor nutrition. Bone measurements will need to be completed to assess additional atrophy and a customized reconstruction plan of bone grafts, bone stabilizers (implants), and a full arch reconstructive prosthetic fabricated. This reconstruction will provide an open palate to help with masticating and taste along with tactical sensation and food aversion.

NV: full treatment plan consultation review with patient and CBCT.

SOAP Note Samples for BOTOX for TMD

S-Chief complaint: Clenching at nighttime, waking headaches, stress due to father in law passing away. Pt receives Botox for migraines from her neurologist, but primarily in the occipital area. She has been on prednisone for her migraines.

HPI-2+ years

Medical hx: Amitryptiline 15mg/day, Nadalol 20mg/day, Maxalt prn pain.

Allergies-none

O-TMD evaluation: Decreased hypertrophy of masseters

Muscle Evaluation: Right and left masseters have mild contraction, les hypertrophy

A-Muscles involved: right and left masseters

P-Tx recommendation: 20 units to each masseter. Advised patient to consider an additional 20 units of Botox (10 units each temporalis).

Consent signed by patient and doctor. Reviewed post-treatment instructions and gave to patient.

Cleaned areas to be treated with isopropyl alcohol.

Areas treated: Right masseter 20 units (0.5 ml) Left masseter 20 units (0.5 ml)

NV: follow-up in one week

Condition: Patient awoke to jaw pain with clicking of bilateral condyle. Dr. Smith diagnosed jaw sprain.

Treatment: 70486 – CBCT 99202 – Exam 21110 - Application of interdental fixation device for conditions other than fracture or dislocation

1. Teeth: You are not necessarily treating teeth, you are treating the infection, structure, caries lesion, erosion as a result of GERD, reconstructing an arch and/or correcting the malformation or trauma to the arch.

2. Emergencies: Many times, we do same day treatment and we should be looking at the definition of emergency. If this patient leaves your practice with the condition they arrived in, will the condition possibly cause immediate difficulties? Pain, infection that could cause septicemia, necrotic bone, atrophy, and many more life-threatening issues.

3. Bone Graft: Most dental insurances do not cover bone grafting in conjunction with an extraction. Identifying the extent of atrophy (minimal, moderate, or severe), along with the why it occurred (infection, xerostomia, or perio), this can be a considered benefit by medical insurance.

4. CBCT: Medical needs to know the symptom of why the image is needed. For instance, your patient comes in with inflammation and pain…that would be the necessity of the image. Unless you are Superman, an x-ray is the only way to accurately diagnose.

5. Bite: When you have a patient that needs a guard, find out what has been going on. The definition of Arthralgia is…pain in a joint; so, the defining issue would be right, left, or bilateral and what has caused it. There is something called, jaw sprain.

Dental Patient Medical Consultation Form

Patient Name: ______Phone: ______

Patient Address: ______

Consult requested by: ______Date: ______

Office Phone Number: ______Office Fax: ______Office E-mail: ______

____Patient scheduled for medical consult: Date: ______Time: ______

____Patient will call to schedule an appointment

Medical Evaluation Request:

Dear Medical Colleague: Please evaluate this patient and provide any medical information that will assist us in providing dental treatment as described below. Dental treatment may be delayed pending your written recommendations. Thank you for your prompt return of this consult.

The patient presents with the following oral diagnoses:

____Gingivitis ____Periodontal disease ____Dental caries _____ Gingival recession

____Dentures ____Impacted teeth ____ Hyposalivation/xerostomia _____ Autoimmune Disease

____Infection or other pathology (Differential Diagnosis): ______

______

Other Findings, Comments: ______

______

Dental Treatment Planned: ______

______

Medical Reason for Evaluation:

____ Diabetes Mellitus ____Hypertension: BP ____/____ Date: ______Heart murmur ____ Cardiovascular disease

____ Bisphosphonate Therapy ____ Pregnancy ____ Joint replacement ____Anticoagulant therapy ____ Other (describe below)

Dentist Signature: ______Date: ______

Please complete medical evaluation on the reverse of this form

Patient authorization to release medical information

I hereby authorize release of my medical information to the dental office requesting this consultation.

Patient Signature: ______Date: ______

Medical Evaluation Report

Evaluation Findings: ______

______

Laboratory Results (HbA1c, PTT, INR etc.): ______

______

Medical Contraindication to Proposed Treatment: ______

______

Recommendations/Follow up: ______

______

Evaluation Completed by (print): ______

Office Phone Number: ______Office Fax: ______E-mail: ______

Provider Signature: ______Date: ______

ABC Insurance 999 Hummingbird Lane Biloxi, MS 44552 Attn: Medical Appeals

June 20, 2014

RE: James Smith DOB: 5/5/1955 DOS: 5/3/2014 ID #ABC123456879 Claim #456789456-01

To Whom It May Concern:

I am writing at this time on behalf of my patient, James Smith, regarding the medical necessity of treatment rendered on May 3, 2014.

James presented on May 3, 2014, after sustaining trauma to the oral region as a result of a basketball injury on May 1, 2014. On clinical examination, James was found to have a vertical fracture of tooth #9 extending below the CEJ to the mesial root. The remainder of his dentition was well maintained, and the periodontium was healthy.

After clinical and radiological review, it was determined that tooth #9 was non-salvageable. (ICD-10 code S02.5XXB)

In order to treat this acute injury, it was necessary to extract tooth #9 (D7140). When the tooth was extracted, it was determined that the labial bony plate was non-existent (due to the traumatic injury) and a ridge preservation was performed (21210) to preserve that area for future restoration with a dental implant (21248).

On behalf of James, your consideration of coverage for the emergency treatment of this traumatic injury is appreciated as well as consideration for future restoration of this tooth. If I may be of further assistance, or if you require additional information, please do not hesitate to contact me at 425.555.1212.

Respectfully,

Laurie Owens Insurance Coordinator Dr. Robert Gottlieb 5723 NE Bothell Way, Ste. C Kenmore, WA 98028

abscess: An acute or chronic localized inflammation, probably with a collection of pus, associated with tissue destruction and, frequently, swelling; usually secondary to infection. acute periradicular or acute apical abscess: An inflammatory reaction to pulpal infection and necrosis characterized by rapid onset, spontaneous pain, tenderness of the tooth to pressure, pus formation, and eventual swelling of associated tissues. This may also be known as an acute periapical abscess, acute alveolar abscess, dentoalveolar abscess, phoenix abscess, recrudescent abscess, or secondary apical abscess. abutment: A tooth or implant fixture used as a support for a prosthesis. abutment crown: An artificial crown also serving for the retention of or support of a dental prosthesis. accession: Addition of a test specimen, previously collected by a health care provider, to a laboratory specimen collection; recording of essential specimen identification data in a laboratory-maintained file in chronological order of laboratory specimen acquisition; assignment to the specimen of an identification code. acid etching: Use of an acidic chemical substance to prepare the tooth enamel and or dentin surface to provide retention for bonding. adhesion: State in which two surfaces are held together by chemical or physical forces or both with or without the aid of an adhesive. Adhesion is one aspect of bonding. adhesive: Any substance that joins or creates close adherence of two or more surfaces. Intermediate material that causes two materials to adhere to each other. adjunctive: A secondary treatment in addition to the primary therapy.

All Rights Reserved © 2020 Devdent - 12338V1 57 Medical Billing for Dentistry | Devdent administrative costs: Overhead expenses incurred in the operation of a dental benefit program, exclusive of costs of dental services provided. administrative services only (ASO): An arrangement under which a third party, for a fee, processes claims and handles paperwork for a self-funded group. This frequently includes all insurance company services (actuarial services, underwriting, benefit description, etc.) except assumption of risk. administrator: One who manages or directs a dental benefit program on behalf of the program's sponsor. See dental benefit organization: third-party administrator. adult dentition: The permanent teeth of adulthood that either replace the primary dentition or erupt distally to the primary molars. adverse selection: A statistical condition within a group when there is a greater demand for dental services and/or more services necessary than the average expected for that group. allogenic: Belonging to the same species, but genetically different. See graft. alloplastic: Refers to synthetic material often used for tissue augmentation or replacement. allowable charge: The maximum dollar amount on which benefit payment is based for each dental procedure as calculated by the third-party payer. alloy: Compound combining two or more elements having properties not existing in any of the single constituent elements. Sometimes used to refer to amalgam. alternate benefit: A provision in a dental plan contract that allows the third-party payer to determine the benefit based on an alternative procedure that is generally less expensive than the one provided or proposed. alternative benefit plan: A plan, other than a traditional (fee-for-service, freedom-of-choice) indemnity or service corporation plan, for reimbursing a participating dentist for providing treatment to an enrolled patient population. alternative delivery system: An arrangement for the provision of dental services in other than the traditional way (e.g., licensed dentist providing treatment in a fee-for-service dental office). alveolar: Referring to the bone to which a tooth is attached. alveoloplasty (also referred to as alveoplasty): Surgical procedure for recontouring supporting bone, sometimes in preparation for a prosthesis.

All Rights Reserved © 2020 Devdent - 12338V1 58 Medical Billing for Dentistry | Devdent amalgam: An alloy used in direct dental restorations. Typically composed of mercury, silver, tin, and copper along with other metallic elements added to improve physical and mechanical properties. analgesia: See definition under anesthesia. anatomical crown: That portion of tooth normally covered by, and including, enamel. ancillary: Subordinate or auxiliary to something or someone else; supplementary. anesthesia: A patient's level of consciousness is determined by the provider and not the route of administration of anesthesia. State dental boards regulate the use of anesthesia techniques. The ADA House of Delegates adopted and has published anesthesia policy and guidelines, which are available online. • Policy Statement: The Use of Sedation and General Anesthesia by Dentists (PDF) • Guidelines for the Use of Sedation and General Anesthesia by Dentists (PDF) • Guidelines for teaching Pain Control and Sedation to Dentists and Dental Students (PDF)

Select definitions from the policy and guidelines follow. Please refer to the cited sources for complete and current information.

Methods of Anxiety and Pain Control analgesia – the diminution or elimination of pain. deep sedation – a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. general anesthesia – a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired. local anesthesia – the elimination of sensation, especially pain, in one part of the body by the topical application or regional injection of a drug.

All Rights Reserved © 2020 Devdent - 12338V1 59 Medical Billing for Dentistry | Devdent minimal sedation – a minimally depressed level of consciousness, produced by a pharmacological method, that retains the patient's ability to independently and continuously maintain an airway and respond normally to tactile stimulation and verbal command. Although cognitive function and coordination may be modestly impaired, ventilatory and cardiovascular functions are unaffected. moderate sedation – a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

Routes of Administration enteral – any technique of administration in which the agent is absorbed through the gastrointestinal (GI) tract or oral mucosa (i.e., oral, rectal, sublingual). inhalation – a technique of administration in which a gaseous or volatile agent is introduced into the lungs and whose primary effect is due to absorption through the gas/blood interface. parenteral – a technique of administration in which the drug bypasses the gastrointestinal (GI) tract (i.e., intramuscular [IM], intravenous [IV], intranasal [IN], submucosal [SM], subcutaneous [SC], intraosseous [IO].) transdermal – a technique of administration in which the drug is administered by patch or iontophoresis through the skin. transmucosal – a technique of administration in which the drug is administered across mucosa such as intranasal, sublingual or rectal.

anomaly: deviation from the normal anatomic structure, growth, development or function; an abnormality.

ANSI/ADA/ISO: Acronyms for organizations that administer or develop national and international standards. ANSI (American National Standards Institute) is the national organization established for the purpose of accrediting and coordinating product standards development activities in the United States. It is not a US government agency. The ADA (American Dental Association) is a national standards development organization accredited by ANSI. ISO (International Organization for Standardization) is a worldwide federation of national standards bodies. The results of ISO technical work are published as International Standards. Efforts in the United States directed toward the development of ISO standards are channeled through ANSI.

ANSI/ADA/ISO Tooth Numbering System: See Specification No. 3950. anterior: Mandibular and maxillary centrals, laterals and cuspids. The designation of permanent anterior teeth in the Universal/National tooth numbering system includes teeth 6 through 11 (maxillary), and 22 through 27 (mandibular); primary teeth in the Universal/National tooth numbering system are designated C through H (maxillary), and M through R (mandibular). Also refers to the teeth and tissues located towards the front of the mouth. anxiolysis: The diminution or elimination of anxiety. any willing provider: Legislation that requires managed care organizations (MCOs), such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs) to contract with any providers who are willing to meet the terms of the contract. apex: The tip or end of the root end of the tooth. apexification: The process of induced root development to encourage the formation of a calcified barrier in a tooth with immature root formation or an open apex. May involve the placement of an artificial apical barrier prior to nonsurgical endodontic obturation. apexogenesis: Vital pulp therapy performed to encourage the continued physiological formation and development of the tooth root. apicoectomy: Amputation of the apex of a tooth. appeal: A formal request that an insurer review denied or unpaid claims for services or supplies provided. An appeal can be filed by a healthcare provider or a patient to recover reimbursement from a third-party payer such as a private insurance company. arch, dental: The curved composite structure of the natural dentition and the residual ridge, or the remains thereof, after the loss of some or all the natural teeth. areas of the oral cavity: A two-digit numeric system used to report regions of the oral cavity to third-party payers. 00 entire oral cavity 01 maxillary arch 02 mandibular arch 10 upper right quadrant 20 upper left quadrant 30 lower left quadrant 40 lower right quadrant arthrogram: A diagnostic X-ray technique used to view bone structures following an injection of a contrast medium into a joint.

All Rights Reserved © 2020 Devdent - 12338V1 61 Medical Billing for Dentistry | Devdent artificial crown: Restoration covering or replacing the major part, or the whole of the clinical crown of a tooth, or implant. assignment of benefits: A procedure whereby a beneficiary/patient authorizes the administrator of the program to forward payment for a covered procedure directly to the treating dentist. audit: An examination of records or accounts to check their accuracy. A post-treatment record review or clinical examination to verify information reported on claims. autogenous: See graft. avulsion: Separation of the tooth from its socket due to trauma. See evulsion.

bad faith insurance practices: The failure to deal with a beneficiary of a dental benefit plan fairly and in good faith; or an activity which impairs the right of the beneficiary to receive the appropriate benefit of a dental benefits plan or to receive them in a timely manner. Some examples of potential bad faith insurance practices include: evaluating claims based on standards which are significantly at variance with the standards of the community; failure to properly investigate a claim for care, and unreasonably and purposely delaying and/or withholding payment of a claim. See prompt payment laws. balance billing: Billing a patient for the difference between the dentist's actual charge and the amount reimbursed under the patient's dental benefit plan. barrier membrane: Usually a thin, sheet-like usually non-autogenous material used in various surgical regenerative procedures. behavior management: Techniques or therapies used to alter or control the actions of a patient who is receiving dental treatment. Examples include use of a papoose board, education or anxiety relief techniques. beneficiary: A person who is eligible for benefits under a dental benefit contract. See also covered person, insured, and member. benefit: The amount payable by a third party toward the cost of various covered dental services or the dental service or procedure covered by the plan. benefit booklet: A booklet or pamphlet provided to the subscriber that contains a general explanation of the benefits and related provisions of the dental benefit program. Also known as a Summary Plan Description.

All Rights Reserved © 2020 Devdent - 12338V1 62 Medical Billing for Dentistry | Devdent benefit plan summary: The description or synopsis of employee benefits as required by ERISA that is to be distributed to the employees. benign: The mild or non-threatening character of an illness or the non-malignant character of a neoplasm. bicuspid: A premolar tooth; a tooth with two cusps. bilateral: Occurring on, or pertaining to, both right and left sides. biologic materials: Agents that alter wound healing or host-tumor interaction. Such materials can include cytokines, growth factor, or vaccines, but do not include any actual hard or soft tissue graft material. These agents are added to graft material or used alone to effect acceleration of healing or regeneration in hard and soft tissue surgical procedures. Also known as biologic response modifiers. biopsy: Process of removing tissue for histologic evaluation. birthday rule: When a dependent child's parents both have dental coverage, this rule states that the primary program (the one which pays first) is the one covering the parent whose month and day of birth falls first in the calendar year. The birthday rule is the most common rule for determining primary v. secondary coverage, but it may be superseded by a court order such as a divorce agreement. bitewing radiograph: Interproximal radiographic view of the coronal portion of the tooth/teeth. A form of a dental radiograph that may be taken with the long axis of the image oriented either horizontally or vertically, that reveals approximately the coronal halves of the maxillary and mandibular teeth and portions of the interdental alveolar septa on the same image. bleaching: Process of lightening of the teeth, usually using a chemical oxidizing agent and sometimes in the presence of heat. Removal of deep-seated intrinsic or acquired discolorations from crowns of vital and non-vital teeth using chemicals, sometimes in combination with the application of heat and light. Bleaching has been achieved through short and long-term applications of pastes or solutions containing various concentrations of hydrogen peroxide and carbamide peroxide. Normally applied externally to teeth; may be used internally for endodontically treated teeth. bonding: Process by which two or more components are made integral by mechanical and/or chemical adhesion at their interface. bounded tooth space: See tooth bounded space.

All Rights Reserved © 2020 Devdent - 12338V1 63 Medical Billing for Dentistry | Devdent bridge: See fixed partial denture. bruxism: The parafunctional grinding of the teeth. buccal: Pertaining to or toward the cheek (as in the buccal surface of a posterior tooth). bundling of procedures: The systematic combining of distinct dental procedure codes by third-party payers that results in a reduced benefit for the patient/beneficiary. by report: A written description of the service provided that is prepared when the term "by report" is included in a procedure code nomenclature; may be requested by a third-party payer to provide additional information for claims processing.

cafeteria plan: Employee benefit plan in which employees select their medical insurance coverage and other nontaxable fringe benefits from a list of options provided by the employer. Cafeteria plan participants may receive additional, taxable cash compensation if they select less expensive benefits. calculus: Hard deposit of mineralized substance adhering to crowns and/or roots of teeth or prosthetic devices. canal: A relatively narrow tubular passage or channel.

root canal - Space inside the root portion of a tooth containing pulp tissue.

mandibular canal - The passage which transmits vessels and nerves through the jaw to branches that distributes them to the teeth. cantilever extension: Part of a fixed prosthesis that extends beyond the abutment to which it is attached and has no additional support. capitation: A capitation program is one in which a dentist or dentists’ contract with the programs' sponsor or administrator to provide all or most of the dental services covered under the program to subscribers in return for payment on a per-capita basis. caries: Commonly used term for tooth decay. carious lesion: A cavity caused by caries. carrier: See third-party.

All Rights Reserved © 2020 Devdent - 12338V1 64 Medical Billing for Dentistry | Devdent case management: The monitoring and coordination of treatment rendered to patients with specific diagnoses or requiring high cost or extensive services. May include complex treatment plans or discussion between multiple practitioners. A process of identifying patients with special health care needs, developing a healthcare strategy that meets those needs, and coordinating and monitoring the care, with the goal of achieving the optimum health care outcome in an efficient and cost-effective manner. cast: See diagnostic cast or study model. cavity: Missing tooth structure. A cavity may be due to decay, erosion or abrasion. If caused by caries; also referred to as carious lesion. cement base: Material used under a filling to replace lost tooth structure. cementum: Hard connective tissue covering the outer surface of a tooth root.

Centers for Medicare and Medicaid Services (CMS): The federal agency responsible for administering the Medicare, Medicaid, State. Children's Health Insurance Program (SCHIP), HIPAA, and the Clinical Laboratory Improvement Amendments (CLIA) programs. CMS is part of the U.S. Department of Health and Human Services. cephalometric image: A standardized, extraoral projection utilized in the scientific study of the measurements of the head. ceramic: see porcelain/ceramic. claim: A request for payment under a dental benefit plan; a statement listing services rendered, the dates of services, and itemization of costs. The completed request serves as the basis for payment of benefits. claim form: A form, paper or electronic, used to report dental procedures to a third-party payer in order to file for benefits under a dental benefit program. The paper claim form was developed by the American Dental Association. claimant: Person or authorized provider who files a claim for benefits. Patient or certificate holder who files a claim for benefits. claims payment fraud: The intentional manipulation or alteration of facts or procedure codes submitted by a treating dentist resulting in a lower payment to the beneficiary and/or the treating dentist that would have been paid if the manipulation had not occurred.

All Rights Reserved © 2020 Devdent - 12338V1 65 Medical Billing for Dentistry | Devdent claims reporting fraud: The intentional misrepresentation of material facts concerning treatment provided and/or charges made, in that this misrepresentation would cause a higher payment.

Classification of Metals: See metals, classification of (source: ADA Council on Scientific Affairs). cleft palate: Congenital deformity resulting in lack of fusion of the soft and/or hard palate, either partial or complete. clenching: The clamping and pressing of the jaws and teeth together in centric occlusion, frequently associated with psychological stress or physical effort. clinical crown: That portion of a tooth not covered by tissues. closed panel: A dental insurance benefit plan which requires the eligible patients to receive their dental care from a specific dentist who has contractually agreed to the terms, payments, and benefits of the plan. Usually, only a limited number of dentists in an area are allowed to participate in these types of plans. closed reduction: The re-approximation of segments of a fractured bone without direct visualization of the boney segments.

CMS: See Centers for Medicare and Medicaid Services.

COB: See coordination of benefits.

Code on Dental Procedures and Nomenclature (Code): A listing of dental procedure codes and their descriptive terms published by the American Dental Association (ADA); used for recording dental services on the patient record as well as for reporting dental services and procedures to dental benefit plans. The Code is printed in a manual titled Current Dental Terminology (CDT). coinsurance: A provision of a dental benefit program by which the beneficiary shares in the cost of covered services, generally on a percentage basis. The percentage of a covered dental expense that a beneficiary must pay (after the deductible is paid). A typical coinsurance arrangement is one in which the third party pays 80% of the allowed benefit of the covered dental service and the beneficiary pays the remainder of the amount due to the dentist. Percentages vary and may apply to the table of allowance plans; maximum allowable benefit plans and direct reimbursement programs. complete denture: A prosthetic for the edentulous maxillary or mandibular arch, replacing the full dentition. Usually includes six anterior teeth and eight posterior teeth.

All Rights Reserved © 2020 Devdent - 12338V1 66 Medical Billing for Dentistry | Devdent complete series: An entire set of radiographs. A set of intraoral radiographs usually consisting of 14 to 22 periapical and posterior bitewing images intended to display the crowns and roots of all teeth, periapical areas and alveolar bone crest (source: FDA/ADA radiographic guidelines). composite: A dental restorative material made up of disparate or separate parts (e.g. resin and quartz particles). compound fracture: Break in bone which is exposed to external contamination. comprehensive oral evaluation: See evaluation.

Consolidated Omnibus Budget Reconciliation Act (COBRA): Legislation relative to mandated benefits for all types of employee benefit plans. The most significant aspects within this context are the requirements for continued coverage for employees and/or their dependents for 18 months who would otherwise lose coverage (30 months for dependents in the event of the employee's death). consultation: In a dental setting, a diagnostic service provided by a dentist where the dentist, patient, or other parties (e.g., another dentist, physician, or legal guardian) discuss the patient's dental needs and proposed treatment modalities. contiguous: Adjacent; touching. contract: A legally enforceable agreement between two or more individuals or entities that confers rights and duties on the parties. Common types of contracts include: 1) contracts between a dental benefit organization and an individual dentist to provide dental treatment to members of an alternative benefit plan. These contracts define the dentist's duties both to beneficiaries of the dental benefit plan and the dental benefit organization, and usually, define the manner in which the dentist will be reimbursed; and 2) contracts between a dental benefit organization and a group plan sponsor. These contracts typically describe the benefits of the group plan and the rates to be charged for those benefits. contract dentist: Any dentist who has a contractual agreement with a dental benefit organization to render care to eligible persons. contract fee schedule plan: A dental benefits plan in which participating dentists agree to accept a list of specific fees for dental treatment provided. contract practice: A dental practice or organization that has a contractual arrangement with an insurer for the provision of services under an insurance contract.

All Rights Reserved © 2020 Devdent - 12338V1 67 Medical Billing for Dentistry | Devdent contract term: Usually a 12-month period for which a contract is written and during which a group's deductibles, maximums and other provisions apply. This may or may not be the same as a calendar year. Also known as the benefit year. contributory program: A dental benefits program in which the enrollee shares in the monthly premium of the program with the program sponsor (usually the employer). Generally done through payroll deduction. coordination of benefits (COB): A method of integrating benefits payable for the same patient under more than one plan. Benefits from all sources should not exceed 100% of the total charges. copayment: Beneficiary's share of the dentist's fee after the benefit plan has paid. coping: A thin covering of the coronal portion of the tooth usually without anatomic conformity. Custom made, or pre-fabricated thimble-shaped core or base layer designed to fit over a natural tooth preparation, a post core, or implant abutment to act as a substructure onto which other components can be added to give final form to a restoration or prosthesis. It can be used as a definitive restoration or as part of a transfer procedure. core buildup: the replacement of a part or all of the crown of a tooth whose purpose is to provide a base for the retention of an indirectly fabricated crown. coronal: Refers to the crown of a tooth. cosmetic dentistry: Those services provided by dentists solely to improve the appearance when form and function are satisfactory, and no pathologic conditions exist [source: ADA policy "Cosmetic Dentistry (1976:850)]. cost containment: Features of a dental benefit program or of the administration of the program designed to reduce or eliminate certain charges to the plan. cost sharing: The share of health expenses that a beneficiary must pay, including the deductibles, copayments, coinsurance, and charges over the amount reimbursed by the dental benefit plan. coverage: Benefits available to an individual covered under a dental benefit plan. covered charges: Services and supplies which are reimbursed in whole or in part under the conditions of the dental benefit plan, subject to all the terms and conditions of the agreement or insurance policy. Charges are subject to any contractual agreements, exclusions, and limitations. Any charges not covered by the plan are considered non-covered charges.

All Rights Reserved © 2020 Devdent - 12338V1 68 Medical Billing for Dentistry | Devdent covered person: An individual who is eligible for benefits under a dental benefit program. covered services: Services for which payment is provided under the terms of the dental benefit contract. cracked tooth syndrome: A collection of symptoms characterized by transient acute pain experienced when chewing. crown: An artificial replacement that restores missing tooth structure by surrounding the remaining coronal tooth structure or is placed on a dental implant. It is made of metal, ceramic or polymer materials or a combination of such materials. It is retained by luting cement or mechanical means. (American College of Prosthodontics; The Glossary of Prosthodontic Terms). See also abutment crown, anatomical crown, clinical crown. crown lengthening: A surgical procedure exposing more tooth for restorative purposes by apically positioning the gingival margin and removing supporting bone. culture and sensitivity test: Clinical laboratory test which identifies a microorganism and the ability of various antibiotics to control the microorganism. curettage: Scraping and cleaning the walls of a real or potential space, such as a gingival pocket or bone, to remove pathologic material.

Current Dental Terminology (CDT): The ADA reference manual that contains the Code on Dental Procedures and Nomenclature and other information pertinent to patient record keeping and claim preparation by a dental office; published biennially (e.g., CDT 2009-2010).

Current Procedural Terminology (CPT): A listing of descriptive terms and identifying codes developed by the American Medical Association (AMA) for reporting practitioner services and procedures to medical plans and Medicare. cusp: Pointed or rounded eminence on or near the masticating surface of a tooth. cuspid: Single cusped tooth located between the incisors and bicuspids. cyst: Pathological cavity, usually lined with epithelium, containing fluid or soft matter.

odontogenic cyst – Cyst derived from the epithelium of odontogenic tissue (developmental, primordial). periapical cyst – An apical inflammatory cyst containing a sac-like epithelium-lined cavity that is open to and continuous with the root canal.

debridement: Removal of subgingival and/or supragingival plaque and calculus which obstructs the ability to perform an evaluation. decay: The lay term for carious lesions in a tooth; decomposition of tooth structure. deciduous: Having the property of falling off or shedding; a term used to describe the primary teeth. deductible: The amount of dental expense for which the beneficiary is responsible before a third party will assume any liability for payment of benefits. The deductible may be an annual or one-time charge and may vary in amount from program to program. See family deductible. deep sedation: See definition under anesthesia. dental assessment: A limited clinical inspection that is performed to identify possible signs of oral or systemic disease, malformation, or injury, and the potential need for referral for diagnosis and treatment. dental benefit organization: Any organization offering a dental benefit plan. Also known as dental plan organization. dental benefits program: The specific dental benefit plan being offered to enrollees by the sponsor. dental enrollment credentialing: A formal process that defines the standards and requirements for participation in third-party programs. The process verifies professional qualifications to allow licensed dentists to provide services to members of these programs. dental home: The ongoing relationship between the dentist who is the Primary Dental Care Provider and the patient, which includes comprehensive oral health care, beginning no later than age one, pursuant to ADA policy. dental prepayment: A method of financing the cost of dental services prior to receiving the services. dental prophylaxis: See prophylaxis. dental service corporation: A legally constituted, not-for-profit organization that negotiates and administers contracts for dental care. Delta Dental Plans and Blue Cross & Blue Shield Plans are such organizations.

All Rights Reserved © 2020 Devdent - 12338V1 70 Medical Billing for Dentistry | Devdent dentin: Hard tissue which forms the bulk of the tooth and develops from the dental papilla and dental pulp, and in the mature state is mineralized. dentistry: The evaluation, diagnosis, prevention and/or treatment (nonsurgical, surgical or related procedures) of diseases, disorders and/or conditions of the oral cavity, maxillofacial area and/or the adjacent and associated structures and their impact on the human body; provided by a dentist, within the scope of his/her education, training and experience, in accordance with the ethics of the profession and applicable law. dentition: The teeth in the dental arch.

adolescent dentition – In orthodontic coding, refers to the stage of permanent dentition prior to cessation of growth. deciduous dentition – Refers to the deciduous or primary teeth in the dental arch. permanent dentition (adult dentition) – Refers to the permanent teeth in the dental arch. transitional dentition – Refers to a mixed dentition; begins with the appearance of the permanent first molars and ends with the exfoliation of the deciduous teeth. denture: An artificial substitute for some or all the natural teeth and adjacent tissues. denture base: That part of a denture that makes contact with soft tissue and retains the artificial teeth. dependents: Generally, spouse and children of a covered individual, as defined by terms of the dental benefit contract. diagnostic cast: A replica of teeth and adjoining tissues created digitally or by a casting process (e.g., plaster into an impression). “Study model” is another term used for such a replica. Diagnostic casts have various uses, most often the examination of relationships between oral tissues to determine how those relationships will effect form and function of a dental restoration or appliance being planned or to determine whether tissue treatment or modification might be necessary before a pre-definitive impression is taken to ensure optimal performance of the planned restoration or appliance. diagnostic imaging: A visual display of structural or functional patterns for the purpose of diagnostic evaluation. May be photographic or radiographic. diastema: Space, such as one between two adjacent teeth in the same dental arch. direct pulp cap: Procedure in which the exposed vital pulp is treated with a therapeutic material, followed by a base and restoration, to promote healing and maintain pulp vitality.

All Rights Reserved © 2020 Devdent - 12338V1 71 Medical Billing for Dentistry | Devdent direct reimbursement: A self-funded program in which the individual is reimbursed based on a percentage of dollars spent on dental care provided, and which allows beneficiaries to seek treatment from the dentist of their choice. direct restoration: A restoration fabricated inside the mouth. discectomy: Excision of the intra-articular disc of a joint. displaced tooth: A partial evulsion of a tooth; may be mesial, distal, facial, lingual or incisal. distal: Surface or position of a tooth most distant from the median line of the arch. downcoding: A practice of third-party payers in which the benefits code has been changed to a less complex and/or lower cost procedure than was reported, except where delineated in contract agreements. dressing: Medication, bandages or other therapeutic material applied to a wound.

DRGs (diagnosis-related groups): A system of classifying hospital patients on the basis of diagnosis, consisting of distinct groupings. A DRG assignment to a case is based on the patient's 1) principal diagnosis; 2) treatment procedures performed; 3) age; 4) gender; and 5) discharge status. dry socket: Localized inflammation of the tooth socket following extraction due to infection or loss of blood clot; osteitis. dual choice program: A benefits package from which an eligible individual can choose to enroll in either an alternative dental benefits program or a traditional dental benefits program.

Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT): A federal program that provides comprehensive health care for children through periodic screenings, diagnostic and treatment services.

ECF: See extended care facility. edentulous: Without teeth. eligibility date: The date an individual and/or dependent become eligible for benefits under a dental benefit contract. Often referred to as effective date. eligible person: See beneficiary.

Employment Retirement Income Security Act (ERISA): A federal act, passed in 1974, which established new standards and reporting/disclosure requirements for employer-funded pension and welfare benefit programs. To date, self-funded health benefit plans operating under ERISA have been held to be exempt from most state insurance laws, although the courts have held that the states can regulate the medical care provided under such plans, as by requiring mandatory review of adverse HMO determinations. enamel: Hard calcified tissue covering dentin of the crown of the tooth. endodontics: Endodontics is the branch of dentistry which is concerned with the morphology, physiology, and pathology of the human dental pulp and periradicular tissues. Its study and practice encompass the basic and clinical sciences including biology of the normal pulp, the etiology, diagnosis, prevention and treatment of diseases and injuries of the pulp and associated periradicular conditions. endodontist: A dental specialist who limits his/her practice to treating disease and injuries of the pulp and associated periradicular conditions. enrollee: Individual covered by a benefit plan. See beneficiary. enteral: See definition under anesthesia. entity: Something that exists as a particular and discrete unit. Persons and corporations are equivalent entities under the law.

EOB: See explanation of benefits.

EPSDT: See Early and Periodic Screening, Diagnosis and Treatment Program. equilibration: Reshaping of the occlusal surfaces of teeth to create harmonious contact relationships between the upper and lower teeth; also known as an occlusal adjustment.

ERISA: See Employment Retirement Income Security Act. established patient: A patient who has received professional services from a dentist or another dentist of the same specialty who belongs to the same group practice, within the past three years, subject to state laws. evaluation: The patient assessment that may include the gathering of information through interview, observation, examination, and use of specific tests that allows a dentist to diagnose existing conditions. Please refer to specific oral evaluation code descriptors for more complete definitions.

Evidence-Based Dentistry: An approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant scientific data relating to the patient's oral and medical condition and history, with the dentist's clinical expertise and the patient's treatment needs and preferences. evulsion: Separation of the tooth from its socket due to trauma. See avulsion. excision: Surgical removal of bone or tissue. exclusions: Dental services not covered under a dental benefit program.

Exclusive Provider Organization (EPO): A type of preferred provider organization under which employees must use providers from the specified network of dentists to receive coverage; there is no coverage for care received from a non-network provider except in an emergency situation. exfoliative: Refers to a thin layer of epidermis shed from the surface. exostosis: Overgrowth of bone. See torus. expiration date: In dentistry, the date on which the dental benefit contract expires; the date an individual will cease to be eligible for benefits. explanation of benefits: A written statement to a beneficiary from a third-party payer, after a claim has been reported, indicating the benefit/charges covered or not covered by the dental benefit plan. extended care facility: A facility such as a nursing home which is licensed to provide 24-hour nursing care service in accordance with state and local laws. Several levels of care may be provided—skilled, intermediate, custodial, or any combination. extension of benefits: Extension of eligibility for benefits for covered services, usually designed to ensure completion of treatment commenced prior to the expiration date. Duration is generally expressed in terms of days. extraoral: Outside the oral cavity. extracoronal: Outside the crown of a tooth. extraction: The process or act of removing a tooth or tooth parts. exudate: A material usually resulting from inflammation or necrosis that contains fluid, cells, and/or other debris.

facial: The surface of a tooth directed toward. the cheeks or lips (i.e., the buccal and labial surfaces) and opposite the lingual surface. family deductible: A deductible that is satisfied by the combined expenses of all covered family members. For example, a program with $25 deductible may limit its application to a maximum of three deductibles, or $75 for the family, regardless of the number of family members. See deductible. fascial: Related to a sheet or band of fibrous connective tissue enveloping, separating or binding together muscles, organs and other soft tissue structures of the body. fee: The monetary value ascribed to a procedure delivered by a dentist to a patient. There are various terms that include the word or concept of a fee that is defined as follows.

full fee – The fee for a service that is set by the dentist, which reflects the costs of providing the procedure and the value of the dentist's professional judgment. A contractual relationship does not change a dentist's full fee. It is always appropriate to report the full fee for each service reported to a third-party payer. maximum plan benefit – The reimbursement level determined by the administrator of a dental benefit plan for a specific dental procedure. This may vary widely by geographic region or by benefit plans within a region. usual fee – The fee which an individual dentist most frequently charges for a specific dental procedure independent of any contractual agreement. It is always appropriate to modify this fee based on the nature and severity of the condition being treated and by any medical or dental complications or unusual circumstances. Usual, Customary and Reasonable Fees (UCR) – These are three separate terms that are often incorrectly used interchangeably, synonymously or as a single term abbreviated as "UCR" when describing dental benefit plans. Definitions of these three terms are posted online at http://www.ada.org. fee-for-service – A method of reimbursement by which the dentist establishes and expects to receive his or her full fee for the specific service(s) performed. fee schedule – A list of the charges established or agreed to by a dentist for specific dental services. filling: A lay term used for the restoring of lost tooth structure by using materials such as metal, alloy, plastic or porcelain. fixed partial denture: A prosthetic replacement of one or more missing teeth cemented or otherwise attached to the abutment teeth or implant replacements.

All Rights Reserved © 2020 Devdent - 12338V1 75 Medical Billing for Dentistry | Devdent flexible benefits: A benefit program in which an employee has a choice of credits or dollars for distribution among various benefit options, e.g., health and disability insurance, dental benefits, childcare, or pension benefits. See cafeteria plans; flexible spending account. flexible spending account: Employee reimbursement account primarily funded with employee designated salary reductions. Funds are reimbursed to the employee for health care (medical and/or dental), dependent care, and/or legal expenses, and are considered a nontaxable benefit. foramen: Natural opening into or through bone. fracture: The breaking of a part, especially of a bony structure; breaking of a tooth. franchise dentistry: Refers to a system for marketing a dental practice, usually under a trade name, where permitted by state laws. In return for a financial investment or other consideration, participating dentists may also receive the benefits of media advertising, a national referral system, and financial and management consultation. freedom of choice: The concept that a patient has the right to choose any licensed dentist to deliver his or her oral health care without any type of coercion. frenum: Muscle fibers covered by a mucous membrane that attaches the cheek, lips and or tongue to the associated dental mucosa. furcation: The anatomic area of a multirooted tooth where the roots diverge.

gate keeper system: A managed care concept used by some alternative benefit plans, in which enrollees select a primary care dentist, usually a general practitioner or pediatric dentist, who is responsible for providing non-specialty care and managing referrals, as appropriate, for specialty and ancillary care. general anesthesia: See anesthesia. genetic test: Laboratory technique used to determine if a person has a genetic condition or disease or is likely to get the disease. gingiva: Soft tissues overlying the crowns of unerupted teeth and encircling the necks of those that have erupted. gingivectomy: The excision or removal of gingiva. gingivitis: Inflammation of gingival tissue without loss of connective tissue.

All Rights Reserved © 2020 Devdent - 12338V1 76 Medical Billing for Dentistry | Devdent gingivoplasty: Surgical procedure to reshape gingiva. glass ionomer: Polyelectrolyte cement in which the solid powder phase is a fluoride- containing aluminosilicate glass powder to be mixed with polymeric carboxylic acid. The cement can be used to restore teeth, fill pits and fissures, lute and line cavities. It is also known as glass polyalkenoate cement, ionic polymer cement, polyelectrolyte cement. gold foil: Thin pure gold leaf that is self-adhering when condensed into a cavity. One of the oldest restorative techniques, it is compacted or condensed into a retentive cavity form. graft: A piece of tissue or alloplastic material placed in contact with tissue to repair a defect or supplement a deficiency.

allograft – Graft of tissue between genetically dissimilar members of the same species. Donors may be cadavers, living related or living unrelated individuals. Also called allogenic graft or homograft.

autogenous graft –Taken from one part of a patient's body and transferred to another. guided tissue regeneration (GTR): A surgical procedure that uses a barrier membrane placed under the gingival tissue and over the remaining bone support to enhance the regeneration of new bone.

Health Care Financing Administration (HCFA): See Centers for Medicare and Medicaid Services.

Health Insurance Portability and Accountability Act (HIPAA) of 1996: A federal law that includes Administrative Simplification Provisions that require all health plans, including ERISA, as well as health care clearinghouses and any dentist who transmits health information in an electronic transaction, to use a standard format. The HIPAA standard electronic dental claim also requires use of the ADA's Code on Dental. Procedures and Nomenclature code set. Paper transactions are not subject to this requirement.

Health Maintenance Organization (HMO): A legal entity that accepts responsibility and financial risk for providing specified services to a defined population during a defined period of time at a fixed price. An organized system of health care delivery that provides comprehensive care to enrollees through designated providers. Enrollees have generally assessed a monthly payment for health care services and may be required to remain in the program for a specified amount of time.

Healthcare Provider Taxonomy: The code that identifies the type of health care provider involved in furnishing services to beneficiaries. hemisection: Surgical separation of a multi-rooted tooth. histopathology: The study of disease processes at the cellular level. hold harmless clause: A contract provision in which one party to the contract promises to be responsible for liability incurred by the other party. Hold harmless clauses frequently appear in the following contexts:

1) Contracts between dental benefit organizations and an individual dentist often contain a promise by the dentist to reimburse the dental benefit organization for any. liability the organization incurs because of dental treatment provided to beneficiaries of the organization's dental benefit plan. This may include a promise to pay the dental benefit organization's attorney fees and related costs; and

2) Contracts between dental benefit organizations and a group plan sponsor may include a promise by the dental benefit organization to assume responsibility for disputes between a beneficiary of the group plan and an individual dentist when the dentist's charge exceeds the amount the organization pays for the service on behalf of the beneficiary. If the dentist acts against the patient to recover the difference between the amount billed by the dentist and the amount paid by the organization, the dental benefit organization will take over the defense of the claim and will pay any judgments and court costs. homologous: See graft. hyperplastic: Pertaining to an abnormal increase in the number of cells in an organ or a tissue with consequent enlargement.

imaging, diagnostic: This would include, but is not limited to, CAT scans, MRIs, photographs, radiographs, etc. immediate denture: Prosthesis constructed for placement immediately after removal of remaining natural teeth. impacted tooth: An unerupted or partially erupted tooth that is positioned against another tooth, bone, or soft tissue so that complete eruption is unlikely. implant: Material inserted or grafted into tissue.

dental implant – A device specially designed to be placed surgically within or on the mandibular or maxillary bone as a means of providing for dental replacement. endosteal (endosseous): Device placed into the alveolar and basal bone of the mandible or maxilla and transecting only one cortical plate.

eposteal (subperiosteal): Subperiosteal implant that conforms to the superior surface of an edentulous area of alveolar bone.

transosteal (transosseous): Device with threaded posts penetrating both the superior and inferior cortical bone plates of the mandibular symphysis and exiting through the permucosa. It may be intraoral or extraoral. implant index: See radiographic. implantation, tooth: Placement of an artificial or natural tooth into an alveolus. inappropriate fee discounting practices: Intentionally engaging in practices which would force a dentist, who does not have a participating provider agreement, to accept discounted fees or be bound by the terms and conditions set forth in the participating provider contract.

**Some examples of inappropriate fee discounting practices include: issuing reimbursement checks which, upon signing, result in the dentist accepting the amount as payment in full; using claim forms which, upon signing, require the dentist to accept the terms of the plan's contract; issuing insurance cards which state that the submittal of a claim by a dentist means that he or she accepts all terms and conditions set forth in the participating provider contract; and sending communications to patients of nonparticipating dentists which state that he or she is not responsible for any amount above usual, customary and reasonable fees as established by the plan. incentive program: A dental benefits program that pays an increasing share of the treatment cost, provided that the covered individual utilizes the benefits of the program during each incentive period (usually a year) and receives the treatment prescribed. For example, a 70%- 30% copayment program in the first year of coverage may become an 80%-20% program in the second year if the subscriber visits the dentist in the first year as stipulated in the program. Most frequently, there is a corresponding percentage reduction in the programs copayment level if the covered individual fails to visit the dentist each year (but never below the initial copayment level). incisal: Pertaining to the biting edges of the incisor and cuspid teeth. incisal angle: One of the angles formed by the junction of the incisal and the mesial or distal surfaces of an anterior tooth; called the mesioincisal and distoincisal angle respectfully.

All Rights Reserved © 2020 Devdent - 12338V1 79 Medical Billing for Dentistry | Devdent incision and drainage: The procedure of incising a fluctuant mucosal lesion to allow for the release of fluid from the lesion. incisor: A tooth for cutting or gnawing; located in the front of the mouth in both jaws. indigent: Those individuals whose income falls below the poverty line as defined by the federal Office of Management and Budget (OMB). indemnification schedule: See table of allowances. indemnity plan: A non-network dental plan that reimburses the member or dentist at a certain percentage of charges for services rendered, often after a deductible has been satisfied. Indemnity plans typically place no restrictions on which dentist a member may visit. Indemnity plans are also referred to as fee-for-service plans. indirect pulp cap: Procedure in which the nearly exposed pulp is covered with a protective dressing to protect the pulp from additional injury and to promote healing and repair via formation of secondary dentin. indirect restoration: A restoration fabricated outside the mouth.

Individual Practice Association (IPA): A legal entity organized and governed by individual participating dentists for the primary purpose of collectively entering into contracts to provide dental services to enrolled populations. inlay: An intracoronal dental restoration, made outside the oral cavity to conform to the prepared cavity, which restores some of the occlusal surfaces of a tooth, but does not restore any cusp tips. It is retained by luting cement. (American College of Prosthodontics; The Glossary of Prosthodontic Terms). insurer: The party in an insurance contract that promises to pay a benefit if a specified loss occurs. Usually an insurance company. insured: Person covered by the program. See beneficiary. intentional reimplantation: The intentional removal, radicular repair, and replacement of a tooth into its alveolus.

International Classification of Diseases (ICD): Diagnostic codes designed for the classification of morbidity and mortality information for statistical purposes; for the indexing of hospital records by disease and operations; and for data storage and retrieval. interproximal: Between the adjoining surfaces of adjacent teeth in the same arch.

ISO Tooth Numbering System: See Specification No. 3950.

jaw: A common name for either the maxilla or the mandible.

JO: Designation of the ANSI/ADA/ISO tooth numbering system on the dental claim form. See Specification No. 3950.

JP: Designation of the Universal/National tooth numbering system on the dental claim form.

keratin: A protein present in all cuticular structures of the body, such as hair, epidermis, and horns. keratinized gingiva: The oral surface of the gingiva extending from the mucogingival junction to the gingival margin. In gingival health, the coronal portion of the sulcular epithelium may also be keratinized.

labial: Pertaining to or around the lip. See facial. laminate veneer: A thin covering of the facial surface of a tooth usually constructed of tooth- colored material used to restore discolored, damaged, misshapen or misaligned teeth. least expensive alternative treatment (LEAT): A type of cost containment measure used by many third-party payers. Under a LEAT clause, when there are multiple treatment options for a specific condition, the plan will only pay for the least expensive treatment. lesion: An injury or wound; area of diseased tissue. liability: An obligation to pay an amount in money, goods, or services to another party. limitations: Restrictive conditions stated in a dental benefit contract, such as age, length of time covered, and waiting periods, which affect an individual's or group's coverage. The contract may also exclude certain benefits or services, or it may limit the extent or conditions under which certain services are provided. See exclusions. limited oral evaluation: See evaluation

All Rights Reserved © 2020 Devdent - 12338V1 81 Medical Billing for Dentistry | Devdent line angle: An angle formed by the junction of two planes; used to designate the junction of two surfaces of a tooth, or of two walls of a tooth cavity preparation. lingual: Pertaining to or around the tongue; the surface of the tooth directed toward the tongue; opposite of facial. local anesthesia: See definition under anesthesia. locus: A site or location.

maintenance, periodontal: Therapy for preserving the state of health of the periodontium. malar: Pertaining to the cheek bone; see zygomatic bone. malignant: Having the properties of dysplasia, invasion, and metastasis. malocclusion: Improper alignment of biting or chewing surfaces of upper and lower teeth. managed care: Any contractual arrangement where payment or reimbursement and/or utilization are controlled by a third party. The term "managed care" refers to a cost containment system that directs the utilization of health benefits by a.) restricting the type, level, and frequency of treatment; b.) limiting the access to care; and c.) controlling the level of reimbursement for services. mandible: The lower jaw.

Maryland bridge: Fixed partial denture featuring conservative retainers which are resin bonded to abutments. maxilla: The upper jaw. maximum plan benefit – The reimbursement level determined by the administrator of a dental benefit plan for a specific dental procedure. This may vary widely by geographic region or by benefit plans within a region.

Medicaid: A federal assistance program established as Title XIX under the Social Security Act of 1965 which provides payment for medical care for certain low-income individuals and families. The program is funded jointly by the state and federal governments and administered by states. medically necessary care: The reasonable and appropriate diagnosis, treatment, and follow- up care (including supplies, appliances, and devices) as determined and prescribed by

All Rights Reserved © 2020 Devdent - 12338V1 82 Medical Billing for Dentistry | Devdent qualified, appropriate health care providers in treating any condition, illness, disease, injury, or birth developmental malformations. Care is medically necessary for: controlling or eliminating infection, pain, and disease; and restoring facial configuration or function necessary for speech, swallowing, or chewing. medicament: Substance or combination of substances intended to be pharmacologically active, specially prepared to be prescribed, dispensed or administered by authorized personnel to prevent or treat diseases in humans or animals. medicament, topical: Pharmacological substance especially prepared to be applied on tissues of the oral cavity.

Medicare: A federal insurance program enacted in 1965 as Title XVIII of the Social Security Act that provides certain inpatient hospital services and physician services for all people age 65 and older and eligible disabled individuals. The program is administered by the Centers for Medicare and Medicaid Services (CMS), previously known as the Health Care Financing Administration (HCFA). member: An individual enrolled in a dental benefit program. See beneficiary. membrane: See barrier membrane. mesial: Nearer the middle line of the body or the surface of a tooth nearer the center of the dental arch. metals, classification of: (source: ADA Council on Scientific Affairs). The noble metal classification system has been adopted as a more precise method of reporting various alloys used in dentistry. The alloys are defined on the basis of the percentage of metal content and listed in order of biocompatibility.

High Noble Alloys — Noble Metal Content > 60% (gold + platinum group*) and gold > 40% Au) Titanium and Titanium Alloys — Titanium (Ti) > 85%. Noble Alloys — Noble Metal Content > 25% (gold + platinum group*). Predominantly Base Alloys — Noble Metal Content) < 25% (gold + platinum group*).

*metals of the platinum group are platinum, palladium, rhodium, osmium, and ruthenium microabrasion: Mechanical removal of a small amount of tooth structure to eliminate superficial enamel discoloration defects. microorganisms: A minute living organism, such as a bacterium, fungus, yeast, virus or Rickettsia.

All Rights Reserved © 2020 Devdent - 12338V1 83 Medical Billing for Dentistry | Devdent molar: Teeth posterior to the premolars (bicuspids) on either side of the jaw; grinding teeth, having large crowns and broad chewing surfaces. moulage: A positive reproduction of a body part formed on a cast from a negative impression. mouthguard: Individually molded device designed primarily to be worn for helping to prevent injury to the teeth and their surrounding tissues. Sometimes called a mouth protector. mucous membrane: Lining of the oral cavity as well as other canals and cavities of the body; also called "mucosa."

National Association of Insurance Commissioners (NAIC): Professional or trade association for state departments of insurance (http://www.naic.org).

National Provider Identifier (NPI): This is an identifier assigned by the federal government to all providers considered to be HIPAA covered entities. Dentists who are not covered entities may elect to obtain an NPI at their discretion or may be enumerated if required by a participating provider agreement with a third-party payer, or applicable state law/regulation. An NPI is unique to an individual dentist or dental entity and has no intrinsic meaning. There are two types of NPI available to dentists and dental practices:

Type 1 Individual Provider — A health care practitioner who is a single human being. ALL dentists are eligible to apply for Type 1 NPIs, regardless of whether they are covered by HIPAA.

Type 2 Organization Provider — A health care provider that is an organization, such as a group practice or corporation. Individual dentists who are incorporated may enumerate as Type 2 providers, in addition to being enumerated as a Type 1. All incorporated dental practices and group practices are eligible for enumeration as Type 2 providers.

On paper, there is no way to distinguish a Type 1 from a Type 2 in the absence of any associated data; they are identical in format. Additional information on NPI and enumeration can be obtained from the ADA's Internet Website: http://www.ada.org/goto/npi. necessary treatment: A necessary dental procedure or service as determined by a dentist, to either establish or maintain a patient's oral health. Such determinations are based on the professional diagnostic judgment of the dentist, and the standards of care that prevail in the professional community.

All Rights Reserved © 2020 Devdent - 12338V1 84 Medical Billing for Dentistry | Devdent non-autogenous: A graft from a donor other than the patient. noncontributory program: A method of payment for group coverage in which the sponsor pays the entire monthly premium for the program. non-covered charges: See covered charges. nonduplication of benefits: Term used to describe one of the ways the secondary carrier may calculate its portion of the payment if a patient is covered by two benefit plans. The secondary carrier calculates what it would have paid if it were the primary plan and subtracts what the other plan paid. For example, if the primary carrier paid 80 percent, and the secondary carrier normally covers 80 percent as well, the secondary carrier would not make any additional payment. If the primary carrier paid 50 percent, however, the secondary carrier would pay up to 30 percent. nonparticipating dentist: Any dentist who does not have a contractual agreement with a dental benefit organization to render dental care to members of a dental benefit program.

obturate: With reference to endodontics, refers to the sealing of the canal(s) of tooth roots during root canal therapy procedure with an appropriately prescribed material such as gutta percha in combination with a suitable luting agent. obturator: A disc or plate which closes an opening; a prosthesis that closes an opening in the palate. occlusal: Pertaining to the biting surfaces of the premolar and molar teeth or contacting surfaces of opposing teeth or opposing occlusion rims. occlusal radiograph: An intraoral radiograph made with the film, phosphorous plate, emulsion, or digital sensor being held between the occluded teeth. occlusal surface: A surface of a posterior tooth or occlusion rim that is intended to contact an opposing occlusal surface. (The Journal of Prosthodontic Dentistry; The Glossary of Prosthodontic Terms; July 2005, page 57) occlusion: Any contact between biting or chewing surfaces of maxillary (upper) and mandibular (lower) teeth. odontogenic: Refers to tooth-forming tissues. odontogenic cyst: See cyst. odontoplasty: Adjustment of tooth length, size, and/or shape; includes removal of enamel projections.

All Rights Reserved © 2020 Devdent - 12338V1 85 Medical Billing for Dentistry | Devdent onlay: A dental restoration made outside the oral cavity that covers one or more cusp tips and adjoining occlusal surfaces, but not the entire external surface. It is retained by luting cement. (American College of Prosthodontics; The Glossary of Prosthodontic Terms) open enrollment: The annual period in which employees can select from a choice of benefit programs. open panel: This type of dental benefits plan allows covered patients to receive care from any dentist and allows any dentist to participate. Any dentist may accept or refuse to treat patients enrolled in the plan. Open panel plans often are described as freedom of choice plans. open reduction: Re-approximation of fractured bony segments accomplished through cutting the adjacent soft tissues and bone to allow direct access. operculectomy: Removal of the operculum. operculum: The flap of tissue over an unerupted or partially erupted tooth. oral: Pertaining to the mouth. oral and maxillofacial pathologist: A dental specialist whose practice is concerned with recognition, diagnosis, investigation, and management of diseases of the oral cavity, jaws, and adjacent structures. oral and maxillofacial pathology: Oral pathology is the specialty of dentistry and discipline of pathology that deals with the nature, identification, and management of diseases affecting the oral and maxillofacial regions. It is a science that investigates the causes, processes, and effects of these diseases. The practice of oral pathology includes research and diagnosis of diseases using clinical, radiographic, microscopic, biochemical, or other examinations. oral and maxillofacial radiologist: A dental specialist whose practice is concerned with the production and interpretation of images and data produced by all modalities of radiant energy used for the diagnosis and management of diseases, disorders, and conditions of the oral and maxillofacial region. oral and maxillofacial radiology: Oral and maxillofacial radiology is the specialty of dentistry and discipline of radiology concerned with the production and interpretation of images and data produced by all modalities of radiant energy that are used for the diagnosis and management of diseases, disorders, and conditions of the oral and maxillofacial region.

All Rights Reserved © 2020 Devdent - 12338V1 86 Medical Billing for Dentistry | Devdent oral and maxillofacial surgeon: A dental specialist whose practice is limited to the diagnosis, surgical and adjunctive treatment of diseases, injuries, deformities, defects, and esthetic aspects of the oral and maxillofacial regions. oral and maxillofacial surgery: Oral and maxillofacial surgery is the specialty of dentistry which includes the diagnosis, surgical and adjunctive treatment of diseases, injuries and defects involving both the functional and esthetic aspects of the hard and soft tissues of the oral and maxillofacial region. oral diagnosis: The determination by a dentist of the oral health condition of an individual patient achieved through the evaluation of data gathered by means of history taking, direct examination, patient conference, and such clinical aids and tests as may be necessary for the judgment of the dentist. oral health literacy: The degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate oral health decisions. orthodontist: A dental specialist whose practice is limited to the interception and treatment of malocclusion and other neuromuscular and skeletal abnormalities of the teeth and their surrounding structures. orthodontics and dentofacial orthopedics: Orthodontics and dentofacial orthopedics is the dental specialty that includes the diagnosis, prevention, interception, and correction of malocclusion, as well as neuromuscular and skeletal abnormalities of the developing or mature orofacial structures. orthognathic: Functional relationship of maxilla and mandible. orthotic device: Apparatus used to support, align, prevent or correct deformities, or to improve the function of movable parts of the body.

OSHA: Abbreviation for Occupational Safety and Health Administration. The federal agency in the US responsible for making and enforcing employee safety regulations. osteoplasty: Surgical procedure that modifies the configuration of bone. osteotomy: Surgical cutting of bone. overbilling: The misrepresentation of a fee as higher than actual charges; for example, when a patient is charged one fee and an insurance company is billed a higher fee to benefit the patient's co-payment, or to increase a fee to a patient solely because the patient is covered under a dental benefits plan.

All Rights Reserved © 2020 Devdent - 12338V1 87 Medical Billing for Dentistry | Devdent overcoding: Reporting a more complex and/or higher cost procedure than was actually performed. overdenture: A removable prosthetic device that overlies and may be supported by retained tooth roots or implants.

palate: The hard and soft tissues forming the roof of the mouth that separates the oral and nasal cavities. palliative: Action that relieves pain but is not curative. panoramic radiograph: An extraoral projection whereby the entire mandible, maxilla, teeth and other nearby structures are portrayed on a single image as if the jaws were flattened out. papoose board: A behavior management technique utilizing immobilization to control the actions of a patient who is receiving dental treatment. parafunctional: Other than normal function or use. parenteral: See definition under anesthesia. partial denture: Usually refers to a prosthetic device that replaces missing teeth. See fixed partial denture or removable partial denture. participating dentist: See contract dentist. patient: An individual who has established a professional relationship with a dentist for the delivery of dental health care. For matters relating to communication of information and consent, this term includes the patient's parent, caretaker, guardian, or another individual as appropriate under state law and the circumstances of the case. payer: A self-insured employer, insurance company, governmental agency or another party responsible for payment of health care claims of covered persons. pediatric dentist: A dental specialist whose practice is limited to treatment of children from birth through adolescence, providing primary and comprehensive preventive and therapeutic oral health care; formerly known as a pedodontist. pediatric dentistry: Pediatric Dentistry is an age-defined specialty that provides both primary and comprehensive preventive and therapeutic oral health care for infants and children through adolescence, including those with special health care needs.

All Rights Reserved © 2020 Devdent - 12338V1 88 Medical Billing for Dentistry | Devdent peer review: An evaluation of the quality and conduct of an individual's work by the individual's professional equals (peers) in order to resolve questions or disputes regarding the quality or conduct of the work. Peer review, when applied to dentistry, is a process, consistently structured and implemented by organized dentistry, in which a dentist's professional equals (peers) resolve questions or disputes (regarding the quality or appropriateness of care provided by the dentist or the fairness of the fee the dentist charged in an individual case) by retrospectively evaluating the quality or appropriateness of care in relation to professional norms or criteria or evaluating the fee charged in relation to the dentist's fee for the given complexity and level of care provided.

Peer Review Organization (PRO): An organization established by an amendment of the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA), to provide for the review of medical services furnished primarily in a hospital setting and/or in conjunction with care provided under the Medicare and Medicaid programs. In addition to their review and monitoring functions, these entities can invoke sanctions, penalties, or other corrective actions for noncompliance in organization standards. percentile: The number in a frequency distribution below which a certain percentage of fees will fall. For example, the 90th percentile is the number that divides the distribution of fees into the lower 90% and the upper 10%, or that fee level at which 90% of dentists charge that amount or less, and 10% more. periapical: The area surrounding the end of the tooth root. periapical abscess: See abscess. periapical cyst: See cyst. periapical radiograph: A radiograph made by the intraoral placement of film, phosphorous plate, emulsion or digital sensor, for disclosing the apices of the teeth. pericoronal: Around the crown of a tooth. periodic oral evaluation: See evaluation. periodontal: Pertaining to the supporting and surrounding tissues of the teeth. periodontal abscess: See abscess. periodontal disease: Inflammatory process of the gingival tissues and/or periodontal membrane of the teeth, resulting in an abnormally deep gingival sulcus, possibly producing periodontal pockets and loss of supporting alveolar bone. periodontal pocket: Pathologically deepened gingival sulcus; a feature of the periodontal disease.

All Rights Reserved © 2020 Devdent - 12338V1 89 Medical Billing for Dentistry | Devdent periodontics: Periodontics is that specialty of dentistry which encompasses the prevention, diagnosis, and treatment of diseases of the supporting and surrounding tissues of the teeth or their substitutes and the maintenance of the health, function and esthetics of these structures and tissues. periodontist: A dental specialist whose practice is limited to the treatment of diseases of the supporting and surrounding tissues of the teeth. periodontitis: Inflammation and loss of the connective tissue of the supporting or surrounding structure of teeth with loss of attachment. periodontium: tissue complex comprising gingival, cementum, periodontal ligament, and alveolar bone which attaches, nourishes, and supports the tooth. periradicular: Surrounding a portion of the root of the tooth. permanent dentition: Refers to the permanent or adult teeth in the dental arch. pin: A small metal rod, cemented or driven into dentin to aid in retention of a restoration. plaque: A soft sticky substance that accumulates on teeth composed largely of bacteria and bacterial derivatives. point of service: A health plan allowing the member to choose to receive a service from a participating or non-participating provider, usually with different benefits levels associated with the use of participating providers. pontic: The term used for an artificial tooth on a fixed partial denture (bridge). porcelain/ceramic: Refers to pressed, fired, polished or milled materials containing predominantly inorganic refractory compounds including porcelains, glasses, ceramics, and glass-ceramics. post: Rod-like component designed to be inserted into a prepared root canal space to provide structural support. This device can either be in the form of an alloy, carbon fiber or fiberglass, and posts are usually secured with appropriate luting agents. posterior: Refers to teeth and tissues towards the back of the mouth (distal to the canines); maxillary and mandibular premolars and molars. The designation of permanent posterior teeth in the Universal/National tooth numbering system includes teeth 1 through 5 and 12 through 16 (maxillary), and 17 through 21 and 28 through 32 (mandibular); primary teeth in the Universal tooth numbering system are designated A, B, I and J (maxillary), and K, L, S and T (mandibular).

All Rights Reserved © 2020 Devdent - 12338V1 90 Medical Billing for Dentistry | Devdent post-treatment review: See audit. preauthorization: Statement by a third-party payer indicating that proposed treatment will be covered under the terms of the benefit contract. See also precertification, predetermination. precertification: Confirmation by a third-party payer of a patient's eligibility for coverage under a dental benefit program. See preauthorization, predetermination. precision attachment: Interlocking device, having a male component integrated into a removable prosthesis that fits precisely into a female component embedded in the body of abutment teeth or implant abutments, to stabilize or retain the prosthesis when it is seated in the mouth. predetermination: A process where a dentist submits a treatment plan to the payer before treatment begins. The payer reviews the treatment plan and notifies the dentist and patient of one or more of the following: patient's eligibility, covered services, amounts payable, copayment and deductibles and plan maximums. pre-existing condition: Oral health condition of an enrollee which existed before his/her enrollment in a dental program.

Preferred Provider Organization (PPO): A formal agreement between a purchaser of a dental benefit program and a defined group of dentists for the delivery of dental services to a specific patient population, as an adjunct to a traditional plan, using discounted fees for cost savings. prefiling of fees: The submission of a participating dentist's full fees to establish, in advance, that dentist's full fees and the fees in a geographic area to determine benefits under a dental benefit program. premedication: The use of medications prior to dental procedures. premium: The amount charged by a dental benefit organization for coverage of a level of benefits for a specified time. premolar: See bicuspid. prepaid dental plan: A method of financing the cost of dental care for a defined population, in advance of receipt of services. prepaid group practice: See closed panel.

All Rights Reserved © 2020 Devdent - 12338V1 91 Medical Billing for Dentistry | Devdent pretreatment estimate: See predetermination. preventive dentistry: Aspects of dentistry concerned with promoting good oral health and function by preventing or reducing the onset and/or development of oral diseases or deformities and the occurrence of oro-facial injuries. primary dentition: The first set of teeth; see deciduous. primary payer: The third-party payer determined to have an initial responsibility in a benefit determination. prior authorization: See predetermination. prompt payment laws: Also known as fair claims practice regulations. Enacted state by state, prompt payment laws set standards for the prompt, fair and equitable settlements of insurance claims by requiring that a set amount of interest be paid on "clean claims" that are paid beyond the established timeframe. "Clean claim" means a claim for payment of covered health care expenses that are submitted to a payer on the carrier's standard claim form using the most current published procedural codes, with all the required fields completed with information sufficient to adjudicate the claim in accordance with the payer's published filing requirements. These laws need to be analyzed on a case by case basis to determine whether a lawsuit must be filed by the state department of insurance. proof of loss: Verification of services rendered or expenses incurred by the submission of claim forms, radiographs, study models, and/or other diagnostic material. Documentary evidence required by a payer to prove a valid claim exists. It usually consists of a claim form completed by the patient's treating dentist. prophylaxis: Removal of plaque, calculus, and stains from the tooth structures. It is intended to control local irritational factors. prospective review: Prior assessment by a payer or payer's agent that proposed services are appropriate for a particular patient, and/or the patient and the category of service are covered by a benefit plan. See preauthorization, precertification, predetermination, second- opinion program. prosthesis: Artificial replacement of any part of the body.

definitive prosthesis – Prosthesis to be used over an extended period of time. dental prosthesis – Any device or appliance replacing one or more missing teeth and/or, if required, associated structures. (This is a broad term which includes abutment crowns and abutment inlays/onlays, bridges, dentures, obturators, gingival prostheses.)

fixed prosthesis – Non-removable dental prosthesis which is solidly attached to abutment teeth, roots, or implants. fixed-removable prosthesis – Combined prosthesis, one or more parts of which are fixed, and the other(s) attached by devices which allow their detachment, removal, and reinsertion by the dentist only. interim prosthesis – A provisional prosthesis designed for use over a limited period, after which it is to be replaced by a more definitive restoration. removable prosthesis – Complete or partial prosthesis, which after an initial fitting by a dentist, can be removed and reinserted by the patient. prosthodontics: Prosthodontics is the dental specialty pertaining to the diagnosis, treatment planning, rehabilitation and maintenance of the oral function, comfort, appearance and health of patients with clinical conditions associated with missing or deficient teeth and/or oral and maxillofacial tissues using biocompatible substitutes. prosthodontist: A dental specialist whose practice is limited to the restoration of the natural teeth and/or the replacement of missing teeth with artificial substitutes. provisional: Formed or preformed for temporary purposes or used over a limited period; a temporary or interim solution; usually refers to a prosthesis or individual tooth restoration. public health dentist: A dentist whose practice is limited to the science and art of preventing and controlling dental diseases and promoting dental health through organized community efforts. public health dentistry: Dental public health is the science and art of preventing and controlling dental diseases and promoting dental health through organized community efforts. It is that form of dental practice which serves the community as a patient rather than the individual. It is concerned with the dental health education of the public, with applied dental research, and with the administration of group dental care programs as well as the prevention and control of dental diseases on a community basis. pulp: Connective tissue that contains blood vessels and nerve tissue which occupies the pulp cavity of a tooth. pulp cap: See direct pulp cap; indirect pulp cap. pulp cavity: The space within a tooth which contains the pulp. pulpectomy: Complete removal of vital and non-vital pulp tissue from the root canal space. pulpitis: Inflammation of the dental pulp.

All Rights Reserved © 2020 Devdent - 12338V1 93 Medical Billing for Dentistry | Devdent pulpotomy: Removal of a portion of the pulp, including the diseased aspect, with the intent of maintaining the vitality of the remaining pulpal tissue by means of a therapeutic dressing. purchaser: Organization or entity, often employer or union, that contracts with the dental benefit organization to provide dental benefits to an enrolled population.

quadrant: One of the four equal sections into which the dental arches can be divided; begins at the midline of the arch and extends distally to the last tooth.

radicular: Pertaining to the root. radiographic/surgical implant index: An appliance, designed to relate osteotomy or fixture position to existing anatomic structures. radiograph: An image or picture produced on a radiation sensitive film, phosphorous plate, emulsion, or digital sensor by exposure to ionizing radiation. rebase: Process of refitting a denture by replacing the base material. recalcification: Procedure used to encourage biologic root repair of external and internal resorption defects. See apexification. reimbursement: Payment made by a third party to a beneficiary or to a dentist on behalf of the beneficiary, to offset expenses incurred for a service covered by the dental benefit plan. reimplantation, tooth: The return of a tooth to its alveolus. reinsurance: Insurance for third-party payers to spread their risk for losses (claims paid) over a specified dollar amount.

Relative Value System (RVU’s): Coded listing of professional services with unit values to indicate relative complexity as measured by time, skill, and overhead costs. Third-party payers typically assign a dollar value per unit to calculate provider reimbursement. reline: Process of resurfacing the tissue side of a removable prosthesis with new base material. removable partial denture: A removable partial denture is a prosthetic replacement of one or more missing teeth that can be removed by the patient.

All Rights Reserved © 2020 Devdent - 12338V1 94 Medical Billing for Dentistry | Devdent resin, acrylic: Resinous material of the various esters of acrylic acid, used as a denture base material, for trays or for other restorations. resin-based composite: See composite. resin infiltration: Application of a resin material engineered to penetrate and fill the sub- surface pore system of an incipient caries lesion to strengthen, stabilize, and limit the lesion's progression, as well as mask visible white spots. retail store dentistry: Refers to dental services offered within a retail, department or drug store operation. Typically, space is leased from the store by a separate administrative group that, in turn, subleases to a dentist or dental group providing the actual dental services. The dental operation generally maintains the same hours of operation as the store and appointments often are not necessary. Considered to be a type of practice, not a dental benefit plan model. retainer: orthodontic retainer – Appliance to stabilize teeth following orthodontic treatment. prosthodontic retainer – A part of a prosthesis that attaches a restoration to the abutment tooth, implant abutment, or implant. retrograde filling: A method of sealing the root canal by preparing and filling it from the root apex. retrospective review: A post-treatment assessment of services on a case-by-case or aggregate basis after the services have been performed. revision: The act of revising; second or more surgical procedure for correction of a condition. risk pool: A portion of provider fees or capitation payments withheld as financial reserves to cover unanticipated utilization of services in an alternative benefit plan. root: The anatomic portion of the tooth that is covered by cementum and is in the alveolus (socket) where it is attached by the periodontal apparatus; a radicular portion of the tooth. residual root – Remaining root structure following the loss of the major portion (over 75%) of the crown. root canal: The portion of the pulp cavity inside the root of a tooth; the chamber within the root of the tooth that contains the pulp. root canal therapy: The treatment of disease and injuries of the pulp and associated periradicular conditions.

All Rights Reserved © 2020 Devdent - 12338V1 95 Medical Billing for Dentistry | Devdent root planing: A definitive treatment procedure designed to remove cementum and/or dentin that is rough, may be permeated by calculus, or contaminated with toxins or microorganisms. rubber dam: A barrier technique used to prevent the passage of saliva or moisture, or to provide an isolated operative field.

salivary gland: Exocrine glands that produce saliva and empty it into the mouth; these include the parotid glands, the submandibular glands, and the sublingual glands. scaling: Removal of plaque, calculus, and stain from teeth. schedule of allowances: See table of allowances. schedule of benefits: A listing of dental services and the maximum benefit amount an insurer will pay for a given service. Specificity will vary by the benefit plan. sealant: A resinous material designed to be applied to the occlusal surfaces of the posterior teeth to prevent occlusal caries. second-opinion program: An opinion about the appropriateness of a proposed treatment provided by a practitioner other than the one making the original recommendation; some benefit plans require such opinions for selected services. sedative filling: A temporary restoration intended to relieve pain. self-funded plan: A benefit plan in which the plan sponsor bears the entire risk of utilization. Some plans may be partially self-funded if the sponsor employs indemnified stop-loss insurance to protect against the risk of unanticipated higher utilization. Third party administrators may provide claims processing and other administrative services, without bearing any of the risks of utilization of the plan. self-insurance: Setting aside of funds by an individual or organization to meet anticipated dental care expenses or its dental care claims, and accumulation of a fund to absorb fluctuations in the amount of expenses or claims. The funds set aside or accumulated are used to provide dental benefits directly instead of purchasing coverage from an insurance carrier. semi-precision attachment: A device, one component of which is fixed to an abutment or abutments and the other is integrated into a fixed or removable prosthesis to stabilize and/or retain it.

All Rights Reserved © 2020 Devdent - 12338V1 96 Medical Billing for Dentistry | Devdent service corporations: Dental benefit organizations established under not-for-profit state statutes to provide health care coverage, e.g., Delta Dental Plans, Blue Cross and Blue Shield Plans. sextant: One of the six relatively equal sections into which a dental arch can be divided, for example: tooth numbers 1-5; 6-11; 12-16; 17-21; 22-27; 28-32. Sometimes used for recording periodontal charting. sialodochoplasty: Surgical procedure for the repair of a defect and/or restoration of a portion of a salivary gland duct. sialography: Inspection of the salivary ducts and glands by radiograph after the injection of a radiopaque medium. sialolithotomy: Surgical procedure by which a stone within a salivary gland or its duct is removed, either intraorally or extraorally. site: A term used to describe a single area, position, or locus. For periodontal procedures, an area of soft tissue recession on a single tooth or an osseous defect adjacent to a single tooth; also used to indicate soft tissue defects and/or osseous defects in edentulous tooth positions. space maintainer: A passive appliance, usually cemented in place, that holds teeth in position.

Specification No. 3950: This schema (ANSI/ADA/ISO Specification No. 3950–1984 Dentistry Designation System for Tooth and Areas of the Oral Cavity) is designed to identify areas of the oral cavity as well as uniquely number permanent and primary dentition. Supernumerary teeth are not yet identified using this standard. For more information see Appendix to Section 3 of this CDT manual. splint: A device used to support, protect, or immobilize oral structures that have been loosened, replanted, fractured or traumatized. Also refers to devices used in the treatment of temporomandibular joint disorders. statistically based utilization review: A system that examines the distribution of treatment procedures based on claims information. To be reasonably reliable, the application of such claims analyses of specific dentists should include data on the type of practice, dentist's experience, socioeconomic characteristics, and geographic location. stomatitis: Inflammation of the membranes of the mouth. stop-loss: A general term referring to that category of coverage that provides insurance protection (reinsurance) to an employer for a self-funded plan.

All Rights Reserved © 2020 Devdent - 12338V1 97 Medical Billing for Dentistry | Devdent stress breaker: That part of a tooth-borne and/or tissue-borne prosthesis designed to relieve the abutment teeth and their supporting tissues from harmful stresses. study model: Plaster or stone model of teeth and adjoining tissues; also referred to as diagnostic cast. See diagnostic cast. succedaneous tooth: A permanent tooth that replaces a primary (deciduous) tooth. summary plan description: See benefit plan summary. supernumerary teeth: Extra erupted or unerupted teeth that resemble teeth of normal shape. suture: Stitch used to repair incision or wound.

table of allowances: A list of covered services with an assigned dollar amount that represents the total obligation of the plan with respect to payment for such service but does not necessarily represent the dentist's full fee for that service.

Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA): Legislation (Public Law 97-248) affecting health maintenance organizations and the Medicare and Medicaid programs. Provides regulations for the development of HMO risk contracting with the Medicare program and, through amendment, established new provisions for the foundation and operation of peer review organizations. temporary removable denture: An interim prosthesis designed for use over a limited period. temporomandibular (TMJ): The connecting hinge mechanism between the base of the skull (temporal bone) and the lower jaw (mandible). temporomandibular joint dysfunction (TMD or TMJD): Abnormal functioning of temporomandibular joint; also refers to symptoms arising in other areas secondary to the dysfunction. termination date: See expiration date. therapeutic: Of or pertaining to therapy or treatment; beneficial. Therapy has as its goal the elimination or control of a disease or other abnormal state. third-party: The party to a dental benefit contract that may collect premiums, assume financial risk, pay claims, and/or provides other administrative services. Also known as administrative agent, carrier, insurer or underwriter. Third-Party Administrator (TPA): Claims

All Rights Reserved © 2020 Devdent - 12338V1 98 Medical Billing for Dentistry | Devdent payer who assumes responsibility for administering health benefit plans without assuming any financial risk. Some commercial insurance carriers and Blue Cross & Blue Shield plans also have TPA operations to accommodate self-funded employers seeking administrative services only (ASO) contracts. third-party payer: An organization other than the patient (first party) or health care provider (second party) involved in the financing of personal health services. tissue conditioning: Material intended to be placed in contact with tissues, for a limited period, with the aim of assisting the return to a healthy condition.

Title XIX: Portion of the Social Security Act that provides for federal grants to the states for medical assistance programs, commonly known as Medicaid. tomography: An X-ray technique that produces an image representing a detailed cross- section of tissue structures at a predetermined depth. tooth bounded space: A space created by one or more missing teeth that have a tooth on each side. torus: A bony elevation or protuberance of bone. See exostosis. tracheotomy: A surgical procedure to create an opening in the trachea (windpipe) to aid in breathing. transitional: Relating to a passage or change from one position, state, phase or concept to another. transitional dentition: Refers to a mixed dentition; begins with the appearance of the permanent first molars and ends with the exfoliation of the deciduous teeth. transplantation: Surgical placement of biological material from one site to another. transplantation of tooth: Transfer of a tooth from one socket to another, either in the same or a different person. transseptal: Through or across a septum. treatment plan: The sequential guide for the patient's care as determined by the dentist's diagnosis and is used by the dentist for the restoration to and/or maintenance of optimal oral health.

All Rights Reserved © 2020 Devdent - 12338V1 99 Medical Billing for Dentistry | Devdent trismus: Restricted ability to open the mouth, usually due to inflammation or fibrosis of the muscles of mastication. tuberosity: A protuberance on a bone.

unbundling of procedures: The separating of a dental procedure into component parts with each part having a charge so that the cumulative charge of the components is greater than the total charge to patients who are not beneficiaries of a dental benefit plan for the same procedure. unerupted: Tooth/teeth that have not penetrated the oral cavity. unilateral: One-sided; pertaining to or affecting but one side.

Universal/National tooth numbering system: A system that assigns a unique number (from 1-32) to permanent teeth, and a unique letter (A-T) for primary teeth. upcode: Reporting a more complex and/or higher cost procedure than was performed. Also known as over coding.

Usual, Customary and Reasonable Fees: See fee. usual fee: See fee. utilization: The extent to which the members of a covered group use a program over a stated period of time; specifically measured as a percentage determined by dividing the number of covered individuals who submitted one or more claims by the total number of covered individuals. Also, an expression of the number and types of services used by the members of a covered group over a specified period of time. utilization management: A set of techniques used by or on behalf of purchasers of health care benefits to manage the cost of health care prior to its provision by influencing patient care decision-making through case-by-case assessments of the appropriateness of care based on accepted dental practices. utilization review, statistically based: A system that examines the distribution of treatment procedures based on claims information and in order to be reasonably reliable, the application of such claims analyses of specific dentists should include data on the type of practice, dentist's experience, socioeconomic characteristics, and geographic location.

veneer: See laminate veneer.

All Rights Reserved © 2020 Devdent - 12338V1 100 Medical Billing for Dentistry | Devdent vertical bitewing: A dental image with a central projection on which the teeth can close, holding it in a vertical position for the radiographic examination of several upper and lower teeth simultaneously. vertical dimension: The vertical height of the face with the teeth in occlusion or acting as stops. vestibuloplasty: Any of a series of surgical procedures designed to increase relative alveolar ridge height. viral culture: A collection of a specimen for the purpose of incubating a virus for identification.

waiting period: The period between employment or enrollment in a dental program and the date when a covered person becomes eligible for a given benefit. wax pattern: A wax form that is the positive likeness of an object to be fabricated. worker's compensation: A benefit paid to an employee who suffers a work-related injury or illness.

xerostomia: Decreased salivary secretion that produces a dry and sometimes burning sensation of the oral mucosa and/or cervical caries. x-ray: See radiograph.

yeast: A general term for a fungus occurring as a unicellular, nucleated organism that usually reproduces by budding. Some yeasts may reproduce by fission, many producing mycelia or pseudo mycelia.

zygomatic bone: Quadrangular bone on either side of face that forms the cheek prominence. See malar.

CPT/HCPCS CODES

Biopsy: 40808 Biopsy – vestibule 41108 Biopsy – floor of mouth 42100 Biopsy – palate

Dentoalveolar Structures: 41800 Drainage of abscess, cyst or hematoma from dentoalveolar structure 41805 Removal of embedded foreign body of dentoalveolar structure, soft tissue 41806 Removal of embedded foreign body from dentoalveolar structure, bone 41820 Gingivectomy, excision gingival, each quadrant 41821 Operculectomy, excision pericorononal tissue 41822 Excision of fibrous tuberosities, dentoalveolar structures 41823 Excision of osseous tuberosities, dentoalveolar structure 41825 Excision of lesion or tumor (except listed above), dentoalveolar structures; without repair 41826 With 41825 with simple repair 41827 With 41825 with complex repair 41828 Excision of hyperplastic alveolar mucosa, each quadrant 41830 Alveolectomy, including curettage of osteitis or sequestrectomy 41850 Destruction of lesion (except incision), dentoalveolar structures 41870 Periodontal mucosal grafting 41874 Alveoplasty, each quadrant 41899 Unlisted procedure, dentoalveolar structures (ALL EXTRACTIONS)

Skull, Facial Bones and Temporomandibular Joint: 21025 Excision of bone (for osteomyelitis or bone abscess); mandible 21206 Excision of facial bone(s) 21031 Excision of torus mandibularis 21032 Excision of maxillary torus palatinus 21480 Closed treatment of TMJ dislocation 21490 Open treatment of TMJ dislocation 21110 Application of interdental fixation for conditions other than fracture or dislocation; includes removal (palatal expander)

Frenectomy: 40806 Incision of labial frenum 41010 Incision of lingual frenum 41520 Frenoplasty (surgical revision of frenum)

Radiology:

70100 Radiologic examination, mandible, partial, less than four views 70140 Radiologic examination, facial bones; less than three views 70150 Radiologic examination, complete, minimum of 3 views 70250 Radiologic examination, skull, less than four views 70300 Radiologic examination, teeth, single view 70310 Radiologic examination, less than full mouth 70320 Radiologic examination, complete full mouth 70328 Radiologic examination, TMJ, open and closed mouth, unilateral 70330 Radiologic examination, TMJ, open and closed mouth, bilateral 70332 TMJ arthrography, radiological supervision, and interpretation 70350 Cephalogram, orthodontic 70355 Orthopantogram (pano) 70486 Computed tomography, maxillofacial area; without contrast material 76376 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality, not requiring image postprocessing on an independent workstation 76377 Same as 76376 requiring image postprocessing on an independent workstation

-TC Technical component modifier – used only if taking the image or film -26 Professional component modifier – used only if interpreting the image

Evaluation and Management Codes (office visits and consultations):

99202 Office visit, new patient, expanded problem focused history and exam, 20 minutes with doctor 99203 Office visit, new patient, detailed history, and exam, 30 minutes with doctor 99211 Office visit, established patient, minimal presenting problems, 5 min 99212 Office visit, established patient, problem focused history and exam, 10 minutes with doctor 99213 Office visit, established patient, expanded problem focused history and exam, 15 minutes with doctor 99241 Office consultation, new or established patient, problem-focused history and exam, straightforward medical decision making 99242 Office consultation, new or established patient, expanded problem focused history and exam, straightforward medical decision making 99243 Office consultation, new or established patient, detailed history and exam, low complexity medical decision making

99244 Office consultation, new or established patient, comprehensive history and exam, moderate complexity medical decision making 99245 Office consultation, new or established patient, comprehensive history and exam, high complexity medical decision making

Ancillary Services:

99070 Diagnostic models (i.e. for TMJ diagnostic work-up)

99070 Supplies and materials ▪ A CPT option for billing diagnostic models if the carrier does not accept D0470 ▪ A CPT option for billing bruxguards if the carrier does not accept D9940 ▪ Requires a description of the service/supply/device and a copy of lab slip/invoice

82397 Chemiluminescent assay (Oral ID, Velscope or ViziLite) 99199 Unlisted special service, procedure, or report

Accident Related Services - Repair of wounds:

12011 Simple repair of superficial wounds of face, ears, eyelids, nose, lips, and/or mucous membranes; 2.5 cm or less 12013 2.6 cm to 5.0 cm 12014 5.1 cm to 7.5 cm 12015 7.6 cm to 12.5 cm 12016 12.6 cm to 20.0 cm 12017 20.1 cm to 30.0 cm 12018 over 30 cm 12051 Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less 12052 2.6 cm to 5.0 cm 12053 5.1 cm to 7.5 cm 12054 7.6 cm to 12.5 cm 12055 12.6 cm to 20.0 cm 12056 20.1 cm to 30.0 cm 12057 over 30.0 cm 13131 Repair, complex, forehead, cheeks, chin, mouth, neck, and/or feet; 1.1 cm to 2.5 cm 13132 2.6 cm to 7.5 cm 13133 each additional 5 cm or less (list separately in addition to code for primary procedure) 13150 Repair, complex, eyelids, nose, ears, and/or lips; 1.0 cm or less 13151 1.1 cm to 2.5 cm

13152 2.6 cm to 7.5 cm 13153 Each additional 5 cm or less (list separately in addition to code for primary procedure) 40830 Closure of laceration, vestibule of mouth; 2.5 cm or less 40831 over 2.5 cm or complex 41250 Repair of laceration 2.5 cm or less; floor of mouth and/or anterior 2/3 of tongue 41251 Posterior one-third of tongue 41252 Repair of laceration of tongue, floor of mouth, over 2.6 cm or complex 42180 Repair, laceration of palate; up to 2 cm 42182 Over 2 cm or complex

Fractures: 21440 Closed treatment of mandibular or maxillary alveolar ridge fracture 21445 Open treatment of mandibular or maxillary alveolar ridge fracture

Miscellaneous:

20670 Removal of implant; superficial (buried wire, pin or rod) 41899 Unlisted procedure, dentoalveolar structures

Oral Appliances/Splints/Orthotics – TMJ: Note: Contact each medical carrier and ask which of the following codes they accept for TMJ orthotics

21085 Occlusal orthotic device ▪ HCPCS code used to report TMJ splint/orthotic to medical

21085 Oral surgical splint ▪ CPT code used to report TMJ diagnostic/pre-surgical splint to medical

21089 Unlisted maxillofacial prosthetic procedure ▪ When a medical carrier does not accept a more specific HCPCS or DME (durable medical equipment) code, CPT code 21089 is used to report TMJ orthotic appliance to medical when fabricated by a dentist – requires a narrative describing procedure/appliance

21299 Unlisted craniofacial and maxillofacial procedure ▪ When a medical carrier does not accept a more specific HCPCS or DME (durable medical equipment) code, CPT code 21299 is used to report TMJ orthotic appliance to medical when designed and placed by a dentist but fabricated by an outside lab

Follow-up Adjustments for TMJ Appliances/Splints/Orthotics:

99212 Follow-up office visit, established patient, problem-focused ▪ Preferred CPT code for reporting TMJ appliance adjustments

97762 Checkout for orthotic/prosthetic use, established patient, each 15 min ▪ Alternative CPT code to report TMJ appliance adjustments

Oral Appliances/Bruxguards/Occlusal Guards: Note: Contact each medical carrier and ask which of the following codes they accept for brux/occlusal guards

21085 Occlusal guard 99070 Supplies and materials

Oral Appliances/Splints/Orthotics – Sleep Apnea:

Note: Contact each medical carrier and ask which of the following codes they accept for brux/occlusal guards

Also note: Most medical carriers will require a letter of medical necessity and referral from the patient’s primary care physician in addition to a copy of the patient’s polysomnogram report validating a sleep apnea diagnosis.

E0485 Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, prefabricated, includes fitting and adjustment.

E0486 Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom, or fabricated, includes fitting and adjustment

▪ These are the preferred HCPCS codes to report sleep apnea appliances. E0485 and E0486 are classified as durable medical equipment (DME) under Medicare, which means a dentist must first enroll in Medicare as a DME provider before the claim will be processed. ▪ Some medical carriers also require the –NU modifier appended to the code the indicate that the appliance/equipment was purchased, not rented.

21089 Unlisted maxillofacial prosthetic procedure ▪ If a medical carrier does not accept the more specific HCPCS code, CPT code 21089 is another option for reporting a sleep apnea appliance to medical when fabricated by a dentist – requires a narrative describing the procedure/appliance.

21299 Unlisted craniofacial and maxillofacial procedure

▪ If a medical carrier does not accept a more specific HCPCS code, CPT code 21299 is another option for reporting a sleep apnea appliance to medical when designed and placed by a dentist but fabricated by an outside lab (requires a narrative describing procedure).

Other Sleep-Related Therapies:

94762 Pulse Oximeter: Non-invasive pulse oximetry for oxygen saturation; by continuous overnight monitoring (separate procedure) 95806 Home sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation; unattended by technologist (including evaluation of patient’s response to therapies) o E.G., Watch-Pat (overnight home sleep study – four channel) o Use modifier -26 for interpretation only o Use modifier -52 for less than 6 hours of recording or other reduced services 95808-95811 Polysomnography; sleep study, attended o Use modifier -26 for interpretation only o Use modifier -52 for less than 6 hours of recording or other reduced services 42145 UPPP (uvulopalatopharyngoplasty) 42299 Somnoplasty (radiofrequency ablation of the palate, uvula)

S2080 Laser-assisted uvulopalatoplasty S8040 Topographic EEG

Other TMJ Related Therapies:

Trigger Point Injections:

20552 Injection(s); single or multiple trigger point(s), one or two muscles 20553 Injection(s); single or multiple trigger point(s), three or four muscles 20605 Arthrocentesis, aspiration and/or injection; interme joint bursa (TMJ) 21073 Manipulation of TMJ, therapeutic, requiring general or monitored anesth 21116 Injection procedure for TMJ arthrography 21465 Open treatment of mandibular condylar fracture 21480 Closed reduction of TMJ dislocation, uncomplicated 21485 Closed reduction of TMJ dislocation, complicated 21490 Open treatment of TMJ dislocation 64400 Trigeminal Nerve Block (or D9212) Botox Injections:

64612 Chemodenervation of muscle(s) innerated by facial nerve and… J0585 Injection, onabotulinumtoxina, one unit

▪ Possible ICD-10 codes: G24.4 Orofacial dyskinesia G50.1 Atypical facial pain R25.0 Abnormal involuntary movements

64613 Chemodenervation of neck muscle(s) (e.g., for spasmodic, torticollis, spasmodic dysphonia)

90772 Therapeutic/diagnostic injection 90901 Biofeedback 92507 Myofunctional therapy (for speech and language disorders) 95867 Electromyography (EMG), unilateral 95868 Electromyography (EMG), bilateral 96002 Surface electromyography (EMG) 97014 Application of a modality to 1 or more areas; electrical stimulation (unattended) Tens unit 97032 Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes Tens unit

Dental Extractions:

For extractions, use CPT 41899 with qualifier above service line and tooth number:

D7140 Extraction, erupted tooth, or exposed root D7210 Surgical removal of erupted tooth D7220 Removal of impacted tooth – soft tissue D7230 Removal of impacted tooth – partially bony D7240 Removal of impacted tooth – completely bony D7241 Removal of impacted tooth – completely bony, with unusual surgical complications

General Anesthesia/IV Sedation:

99152 Intravenous conscious sedation/anesthesia – first 15 minutes 99153 Intravenous conscious sedation/anesthesia – each addtl 15 minutes

Dental Implant Surgical Guide: 21085 Oral surgical splint or stent

Placement of Dental Implant Body:

21248 Reconstruction of mandible or maxilla, endosteal implant, partial 1-3 implants 21249 Reconstruction of mandible or maxilla, endosteal implant, complete 4+

Bone Grafts – Ridge Augmentation:

21210 Graft, bone, nasal, maxillary (add modifier -52 if using freeze dried bone) 21215 Graft, bone, nasal, mandible (add modifier -52 if using freeze-dried bone) 21125 Augmentation, mandibular body or angle (for block graft) 21127 Augmentation, mandibular body or angle; with bone graft (add modifier -52 if using freeze-dried bone) 21299 Unlisted craniofacial and maxillofacial procedure ▪ Requires narrative describing procedure

Platelet Rich Plasma (PRP):

0232T Injection(s) platelet rich plasma, any tissue, including image guidance, harvesting, and preparation when performed

Platelet Rich Fibrin (PRF):

0481T Consists of the following three layers; topmost layer consisting of platelet poor plasma, PRF clot in the middle, and red blood cells at the bottom.

Recommended ICD-10 diagnosis codes for Dental Billing and Claims to Medical:

Z00-Z99 – Factors influencing health status and contact with health services:

Z01.20 Encounter for Routine dental check-up no abnormal findings Z01.21 Encounter for Routine dental check-up WITH abnormal findings

K00 – Disorders of tooth development and eruption: K00.0 Anodontia K00.1 Supernumerary teeth K00.2 Abnormalities of tooth size and form K00.3 Mottled teeth (Fluorosis) K00.4 Disturbances in tooth formation K00.5 Hereditary disturbances in tooth structure, not elsewhere classified K00.6 Disturbances in tooth eruption (natal/neonatal teeth, retained deciduous) K00.7 Teething syndrome K00.8 Other disorders of tooth development K00.9 Disorders of tooth development, unspecified

K01 – Embedded and impacted teeth: K01.0 Embedded teeth K01.1 Impacted teeth

K02 – Dental caries: K02.3 Arrested dental caries K02.51 Dental caries on pit and fissure surface limited to enamel K02.52 Dental caries on pit and fissure surface, penetrating into dentin K02.53 Dental caries on pit and fissure surface, penetrating into pulp K02.61 Dental caries on smooth surface limited to enamel K02.62 Dental caries on smooth surface, penetrating into dentin K02.63 Dental caries on smooth surface, penetrating into pulp K02.7 Dental root caries

K03 – Other diseases of hard tissue:

K03.0 Excessive attrition of teeth K03.1 Abrasion of teeth K03.2 Erosion of teeth K03.3 Pathological resorption of teeth

K03.4 Hypercementosis K03.5 Ankylosis of teeth K03.6 Deposits (accretions) on teeth (Diagnostic for scaling/root planing) K03.7 Posteruptive colour change of dental hard tissues K03.81 Cracked tooth K03.9 Diseases of hard tissue or teeth, unspecified

K04 – Diseases of the pulp and periapical tissue: K04.0 Pulpitis K04.01 Reversible pulpitis K04.02 Irreversible pulpitis K04.1 Necrosis of pulp K04.2 Pulp degeneration K04.3 Abnormal hard tissue formation in pulp K04.4 Acute apical periodontitis of pulpal origin K04.5 Chronic apical periodontitis K04.6 Periapical abscess with sinus K04.7 Periapical abscess without sinus K04.8 Radicular cyst K04.9 Other specified and unspecified diseases of the pulp and periapical tissues

K05 – Gingivitis and periodontal diseases:

K05.0 Acute gingivitis K05.00 Acute gingivitis – plaque induced K05.01 Acute gingivitis – non-plaque induced

K05.1 Chronic gingivitis K05.10 Chronic gingivitis – plaque induced K05.11 Chronic gingivitis – non-plaque induced

K05.2 Aggressive periodontitis (includes acute pericoronitis) K05.21 Aggressive periodontitis – localized K05.211 Aggressive periodontitis – localized slight K05.212 Aggressive periodontitis – localized moderate K05.213 Aggressive periodontitis – localized severe

K05.3 Chronic periodontitis (includes chronic pericoronitis) K05.31 Chronic periodontitis – localized K05.311 Chronic periodontitis – localized slight K05.312 Chronic periodontitis – localized moderate K05.313 Chronic periodontitis – localized severe

K05.32 Chronic periodontitis – generalized K05.321 Chronic periodontitis – generalized slight K05.322 Chronic periodontitis – generalized moderate K05.323 Chronic periodontitis – generalized severe

K05.4 Periodontosis (juvenile) K05.5 Other periodontal disease K05.6 Periodontal disease, unspecified

K06 – Other diseases of the gingiva and edentulous alveolar ridges:

K06.01 Gingival recession – localized K06.011 Localized gingival recession – minimal K06.012 Localized gingival recession – moderate K05.013 Localized gingival recession – severe

K06.02 Gingival recession – generalized K06.021 Generalized gingival recession – minimal K06.022 Generalized gingival recession – moderate K05.023 Generalized gingival recession – severe

K06.1 Gingival enlargement K06.2 Gingiva and edentulous alveolar ridge lesions associated with trauma K06.3 Horizontal alveolar bone loss K06.8 Other specified disorders of the gingiva and edentulous alveolar ridge

K06.9 Disease of the gingiva and edentulous alveolar ridge, unsp

K08 – Other disorders of the teeth and supporting structures:

K08.0 Exfoliation of teeth due to systemic disorders (Hypophosphatasia, scurvy)

K08.11 Complete loss of teeth, trauma K08.111 Complete loss of teeth, trauma, class I K08.112 Complete loss of teeth, trauma, class II K08.113 Complete loss of teeth, trauma, class III K08.114 Complete loss of teeth, trauma, class IV

K08.12 Complete loss of teeth, perio disease K08.121 Complete loss of teeth, perio disease, class I K08.122 Complete loss of teeth, perio disease, class II K08.123 Complete loss of teeth, perio disease, class III K08.124 Complete loss of teeth, perio disease, class IV

K08.13 Complete loss of teeth, caries K08.131 Complete loss of teeth, caries, class I K08.132 Complete loss of teeth, caries, class II K08.133 Complete loss of teeth, caries, class III K08.134 Complete loss of teeth, caries, class IV

K08.19 Complete loss of teeth due to other systemic cause K08.191 Complete loss of teeth other systemic, class I K08.192 Complete loss of teeth other systemic, class II K08.193 Complete loss of teeth other systemic, class III K08.194 Complete loss of teeth other systemic, class IV

K08.2 Atrophy of edentulous alveolar ridge (use for bone grafts) K08.21 Minimal atrophy of the mandible K08.22 Moderate atrophy of the mandible K08.23 Severe atrophy of the mandible K08.24 Minimal atrophy of the maxilla K08.25 Moderate atrophy of the maxilla K08.26 Severe atrophy of the maxilla

K08.3 Retained dental root

K08.41 Partial loss of teeth, trauma K08.411 Partial loss of teeth, trauma, class I K08.412 Partial loss of teeth, trauma, class II K08.413 Partial loss of teeth, trauma, class III K08.414 Partial loss of teeth, trauma, class III

K08.42 Partial loss of teeth, perio K08.421 Partial loss of teeth, perio, class I K08.422 Partial loss of teeth, perio, class II K08.423 Partial loss of teeth, perio, class III K08.424 Partial loss of teeth, perio, class IV

K08.43 Partial loss of teeth, caries K08.431 Partial loss of teeth, caries, class I K08.432 Partial loss of teeth, caries, class II K08.433 Partial loss of teeth, caries, class III K08.434 Partial loss of teeth, caries, class IV

K08.49 Partial loss of teeth due to other specified cause

K08.491 Partial loss of teeth other specified cause, class I K08.492 Partial loss of teeth other specified cause, class II K08.493 Partial loss of teeth other specified cause, class III K08.494 Partial loss of teeth other specified cause, class IV

K08.5 Unsatisfactory restoration of a tooth K08.51 Open restoration margins of a tooth K08.52 Unrepairable overhanging of a dental restorative material K08.53 Fractured dental restorative material K08.530 Fractured dental restorative material w/o loss of material K08.531 Fractured dental restorative material w/loss of material K08.54 Contour of existing restoration of tooth biological incompatible with oral health K08.55 Allergy to existing dental restorative material K08.56 Poor aesthetic of existing restoration of a tooth

K08.8 Other specified disorders of teeth and supporting structures K08.81 Primary occlusal trauma K08.82 Secondary occlusal trauma

K08.9 Disorders of teeth and supporting structures, unspecified

K09 – Cysts of oral origin, not elsewhere classified: K09.0 Developmental odontogenic cysts K09.1 Developmental (non-odontogenic) cysts of oral origin K09.2 Other cysts of jaws (aneurismal bone cyst) K09.8 Other cysts of oral region, not elsewhere classified (dermoid) K09.9 Cysts of oral region, unspecified

K10 – Other diseases of jaws: K10.0 Developmental disorders of jaws (Tori) K10.1 Giant cell granuloma, central K10.2 Inflammatory conditions of jaws (Osteomyelitis, sequestra) K10.3 Alveolitis of jaws (dry socket) K10.8 Other specified diseases of jaws K10.9 Disease of jaws, unspecified

K11 – Diseases of the salivary glands: K11.0 Atrophy of salivary gland K11.1 Hypertrophy of salivary gland K11.2 Sialoadenitis K11.21 Acute Sialoadenitis K11.22 Acute recurrent Sialoadenitis K11.23 Chronic Sialoadenitis

K11.3 Abscess of salivary gland K11.4 Fistula of salivary gland K11.5 Sialolithiasis (salivary calculus) K11.6 Mucocoele of salivary gland K11.7 Disturbances of salivary secretion (Xerostomia) K11.8 Other diseases of salivary glands (Miculicz) K11.9 Disease of salivary gland, unspecified

K12 – Stomatitis and related lesions: K12.0 Recurrent oral aphthae K12.1 Other forms of stomatitis K12.2 Cellulitis and abscess of mouth

K13 – Other diseases of the lip and oral mucosa: K13.0 Diseases of lips (Angular cheilitis) K13.1 Cheek and lip biting K13.2 Leukoplakia and other disturbances of the oral epithelium, includ tongue K13.21 Leukoplakia of oral mucosa including tongue K13.22 Minimal keratinized residual ridge mucosa K13.23 Excessive keratinized residual ridge mucosa K13.24 Leukokeratosis nicotina palati – smoker’s palate K13.3 Hairy Leukoplakia K13.4 Granuloma – like lesions of oral mucosa (pyogenic granuloma) K13.5 Oral submucous fibrosis K13.6 Irritative hyperplasia of oral mucosa K13.7 Other and unspecified lesions of oral mucosa

K14 – Diseases of the tongue: K14.0 Glossitis (ulcer, abscess) K14.1 Geographic tongue K14.2 Median Rhomboid Glossitis K14.3 Hypertrophy of papillae (black hairy tongue) K14.4 Atrophy of papillae K14.5 Plicated tongue (scrotal, fissured) K14.6 Glossodynia K14.8 Other diseases of the tongue K14.9 Disease of the tongue, unspecified

M26 – Dentofacial anomalies (including malocclusion)

M26.0 Major anomalies of jaw size M26.01 Maxillary hyperplasia M26.02 Maxillary hypoplasia

M26.03 Mandibular hyperplasia M26.04 Mandibular hypoplasia M26.05 Macrogenia M26.06 Microgenia M26.07 Excessive tuberosity of jaw

M26.1 Anomalies of jaw-cranial base relationship M26.11 Maxillary asymmetry M26.12 Other jaw asymmetry

M26.2 Anomalies of dental arch relationship M26.211 Malocclusion, Angle’s class 1 M26.212 Malocclusion, Angle’s class II M26.213 Malocclusion, Angle’s class III M26.220 Open anterior occlusal relationship M26.221 Open posterior occlusal relationship M26.23 Excessive spacing M26.24 Reverse articulation M26.25 Anomalies of interarch distance

M26.3 Anomalies of tooth position of fully erupted tooth or teeth M26.31 Crowding of fully erupted teeth M26.32 Excessive spacing M26.33 Horizontal displacement of teeth (tipped tooth) M26.34 Vertical displacement of teeth (extruded tooth) M26.35 Rotation of fully erupted teeth/tooth M26.36 Insufficient interocclusal distance M26.37 Excessive interocclusal distance M26.4 Malocclusion unspecified

M26.5 Dentofacial function abnormalities M26.51 Abnormal jaw closure M26.52 Limited mandibular range of motion M26.53 Deviation in opening and closing mandible M26.54 Insufficient anterior guidance M26.55 Centric occlusion maximum intercuspation discrepancy M26.56 Non-working side interference M26.57 Lack of posterior occlusal support

M26.6 Temporomandibular joint disorders M26.611 Adhesions and ankylosis of right TMJ M26.612 Adhesions and ankylosis of left TMJ M26.613 Adhesions and ankylosis of bilateral TMJ

M26.621 Arthralgia of right TMJ M26.622 Arthralgia of left TMJ M26.623 Arthralgia of bilateral TMJ M26.631 Articular disc disorder of right TMJ M26.632 Articular disc disorder of left TMJ M26.633 Articular disc disorder of bilateral TMJ

M26.7 Dental alveolar anomalies M26.71 Alveolar maxillary hyperplasia M26.72 Alveolar mandibular hyperplasia M26.73 Alveolar maxillary hypoplasia M26.74 Alveolar mandibular hypoplasia M26.81 Anterior soft tissue impingement M26.82 Posterior soft tissue impingement

M27.6 Endosseous dental implant failure M27.61 Osseointegration failure of dental implant M27.62 Post osseointegration biological failure of dental implant M26.63 Post osseointegration mechanical failure of dental implant

Miscellaneous Codes:

T85.9XXA Unsp complication of internal prosthetic device, implant, and graft (use for implant removal) K08.9 Toothache (use this only when the diagnosis is not found elsewhere) J01.10 Acute maxillary sinusitis J01.11 Acute recurrent sinusitis Z46.4 Fitting and adjustment of orthodontic devices F45.8 Bruxism G47.63 Sleep-related bruxism Q38.0 Congenital malformation of lips NOS (use for frenectomy, not cleft lip) E08.630 Diabetes due to underlying condition with periodontal disease E08.638 Diabetes due to underlying condition with other oral complications E09.630 Drug or chemical induced diabetes mellitus with periodontal disease E10.630 Type 1 diabetes mellitus with periodontal disease E11.630 Type 2 diabetes mellitus with periodontal disease E13.630 Other specified diabetes mellitus with periodontal disease F40.232 Fear of other medical care (use for IV sedation) G35 Multiple Sclerosis G30.9 Alzheimer’s Disease – unspecified G20 Parkinson’s Disease G40.9 Epilepsy – unspecified

Notes: