LAC 40:I.5315. Coding System

A. Resources: 1. CDT-1 manual: Council on Dental Care Programs American Dental Association 211 East Chicago Avenue Chicago, Illinois 60611 (312) 440-2500 2. CPT manual: AMA Order Dept. Box 10946 Chicago, Illinois 60610 (800) 621-8335 3. ADA dental claim form: Council on Dental Care Programs American Dental Association 211 East Chicago Avenue Chicago, Illinois 60611 (312) 440-2500 4. HCPCS Manual MAP 671 Executive Drive Willowbrook, Illinois 60521 (312) 440-2500 5. NDAS Manual National Dental Advisory Service P.O. Box 510949 Milwaukee, WI 53203 (800) 669-3337 6. Relative Values for Dentists Relative Value Studies, Inc. P.O. Box 6431 Denver, Colorado 80206 (303) 329-9787 B. CDT-1 Coding 1. For convenience, the current Dental Terminology, First Edition (CDT-1) procedure codes are divided into 12 categories of service. Additional coding systems such as ICD-9, CPT, HCPCS and NDAS coding may also be used in the dental office. 2. Additional dental service codes from Relative Values for Dentists have been included where it was felt that more descriptive coding would be beneficial. 3. Procedures denoted “BR” (by report) in the fee schedule should be justified by the submission of a report. 4. All fees should include the price of materials supplied and the performance of the service. Under some circumstances, however, fee adjustments are necessary and values of listed codes may be modified by use of the appropriate “modifier code number.” Modifiers available. 22 | Unusual Services―Report required. 50 | Bilateral or Multiple Field Procedures―Multiple procedures in separate anatomical field. The following values may be used: 100 percent first major procedure. 70 percent each additional field procedure. 51 | Multiple Procedures―Multiple procedure in the same anatomical field. The following values may be used: Single Field 100 percent for first major procedure 50 percent of listed value for second 25 percent of listed value for third 10 percent of listed value for fourth 5 percent of listed value for fifth BR for any procedure beyond 5 52 | Reduced Values―Reduced or estimated value for procedure because of common practice or at the dentist’s election. 53 | Primary Emergency Services―Procedure is carried out by a dentist who will not be providing the follow-up care. The value may be 70 percent of the listed value. 54 | Surgical Procedure Only―Used to identify the dentist performing surgery. The value may be 70 percent of the listed value. 55 | Follow-Up Care Only―Identifies the dentist providing follow-up care. The value may be 30 percent of the listed value. 56 | Pre-Operative Care Only―Identifies the dentist performing care up until surgery when another dentist takes over. Value may be 30 percent of the listed value. 75 | Services Rendered by More than One Dentist―When the condition requires more than one dentist, each dentist may be allowed 80 percent of the value for that procedure 99 | Multiple ModifiersBy Report The use of modifiers does not imply or guarantee that a provider will receive reimbursement as billed. Reimbursement for modified services or procedures must be based on documentation of medical necessity and must be determined on a case-by-case basis. 5. Fees for surgical procedures should be global in nature and include the surgery, any local anesthesia and normal follow-up care. Fees for general anesthesia are extra as are complications or additional services and should be coded separately.