Are you required to apply diagnosis codes to the dental claim, or will you be required to do so?

The short answer to this question is, sometimes. Since the announcement of the revision of the ADA Dental Claim form effective January 1, 2024, there have been a lot of assumptions made, and yes, at times, you may have received misleading information. This article will address the 2024 claim form and the requirement to append diagnosis codes using the ICD-10-CM code set. I hope this article will clarify what diagnosis codes are and when they may be applicable.

What are diagnosis codes?

Diagnosis codes communicate a diagnosis, condition, symptoms, and procedures across healthcare systems and track diseases and morbidity. This is not medical coding, despite what you may have heard in the past few years. It is simply another code set that serves a different purpose than Current Dental Terminology (CDT), which we are most familiar with in dentistry. In dentistry, historically, we have communicated symptoms, diagnoses, or conditions treated in the form of a wordy written narrative entered in the remarks section of the ADA Dental Claim Form. A code can be applied to the claim form instead of using a written narrative to describe what condition is being treated. A diagnosis code proves and establishes medical or dental necessity. For many years, at least one diagnosis code has been required for medical claims.

Brief History of ICD-10 Code Set in the United States

ICD is the acronym for the International Classification of Diseases. In the U.S., we utilize two ICD code sets, clinical modification (CM) and Procedure Coding Systems (PCS). A dentist will not use an ICD-10-PCS code. The PCS set is strictly used by facilities such as hospitals and reports inpatient procedures. Even if the dentist treats a patient in a hospital, she will select a code from the ICD-10-CM code set.

In 2008, the U.S. Department of Health and Human Services (HHS) issued a proposed rule to transition from ICD-9 to ICD-10 on October 1, 2011. At the time, ICD-9 was 35 years old and outdated. Many physicians and other healthcare stakeholders expressed that time was needed for the transition. So, in the 2009 final rule, HHS established October 1, 2013, as the date for the transition to give U.S. healthcare providers two additional years to prepare.

In 2012, as part of President Obama’s commitment to reducing regulatory burden, HHS moved the implementation of the ICD-10 date to October 1, 2014, providing the industry with an additional year to work toward a successful transition. As healthcare providers diligently prepared for implementation, it was delayed until October 1, 2015. The Protecting Access to Medicare Act of 2014 (PAMA), enacted on April 1, 2014, prohibited the HHS Secretary from adopting ICD-10 before October 1, 2015. The ICD-10 code set became effective for all dates of services beginning October 1, 2015.

ICD-10 includes thousands more codes than ICD-9, allowing for greater specificity. Was it a learning curve for the entire healthcare industry, including dentists? Yes, absolutely, it was.

How does documentation come into play?

Like our CDT code set, which we use to document dental procedures performed and report to third-party payers, only what is documented can be reported. I recall attending my first ICD-10 workshop in 2014. The workshop topic was teaching healthcare providers how to document for ICD-10. Wow, was that an enlightening workshop! It was in that seminar that I realized our clinical documentation in dentistry was significantly lacking. I knew we needed to start teaching how to document with greater specificity. Teaching the importance of documentation began in 2014, and I’ve continued teaching since then.

As much as I love dentists and have many friends who are dentists, I can say lovingly that they are not historically known for their thoroughness in documentation like our medical doctors. Lack of specificity in documentation remains our number one root cause for claims denials, reimbursement delays, and audit outcomes. Proving a dental procedure is medically necessary has not been something we focused on in dentistry until now. We must improve and include greater specificity in our clinical documentation. Everyone on the dental team is responsible for ensuring accuracy in documentation.

Are the diagnosis code fields new to the claim form?

No, these are not new fields on the 2024 ADA Dental Claim Form. Looking back to 2011, the ADA Dental Claim Form 2006 version was revised, including adding the fields 29a, 34, and 34a, where we enter ICD-10-CM code information. This new version became effective January 1, 2012.

While at the time of the revision to the 2012 ADA Dental Claim Form, adding these diagnosis code fields, there was no confirmation from any state or federally funded programs as to when this would be required. There was discussion among some state Medicaid programs that they would require the application of diagnosis codes on dental claims in 2014, but there was no confirmation of this. However, the ADA was forward-thinking, considering the implementation of the Affordable Care Act on January 1, 2014, and ICD-10, which was initially scheduled to be implemented on October 1, 2014.

Why state and federally funded programs?

We’ve already learned that data regarding diseases and morbidity is gathered from applying ICD codes on claims. State and federally funded programs also use diagnosis codes to determine what we, as healthcare providers, do to prevent diseases. In other words, are we screening for disease, thus taking measures in disease prevention?

In the spring of 2014, I received a call from the executive director of the Southern Nevada Dental Association asking for help teaching dental Medicaid providers how to apply diagnosis codes to the dental claim form. Nevada was the first state Medicaid program I was aware of requiring the application of diagnosis codes on ALL dental claims. These providers were not being paid by Medicaid due to the omission of diagnosis codes. Our work was cut out for us, and we were up for the challenge.

I had just begun working alongside Dr. Charles Blair a few months before receiving this call regarding the problem dentists were facing in Nevada. Dr. Blair, myself, and my colleague, Glenda Hood, CPC, put our heads together on how to teach diagnosis coding to dental teams. Dr. Blair and I combined our dental knowledge with Glenda’s 30+ years of medical coding and billing experience. We set out to create a resource quickly, as these dentists were not being paid and needed to be paid.

Due to the delayed implementation of ICD-10 in 2015, these Nevada dentists had to learn ICD-9 and ICD-10. Glenda and I had the idea we would create a 25-page reference guide they could keep in their desk drawer. The three of us decided that clinical scenarios would be the best way to teach this new concept. We quickly began to write clinical scenarios, research appropriate codes, and design an easy to use publication. I might add that the original design was completed using Microsoft Word, not fancy software, as we needed to get this resource to dentists as quickly as possible. In true Dr. Blair style, that 25-page reference guide promptly expanded into a 250 page book with chapters on navigating Medicaid. We got our designer, Margaret Macknelly, and the entire PracticeBooster team involved, and in the fall of 2014, the first edition of “Diagnostic Coding for Dental Claim Submission” 2015 edition was released. Dr. Blair’s Scenario-Based Teaching Method™ was released.

Fun Fact! When I resigned from Dr. Charles Blair and PracticeBooster, Dr. Blair gifted me with the original cover designs and book design started in Word, which I will always cherish. We spent many hours, evenings, weekends, early mornings, and even as I was riding in the car on vacation or on a plane, developing this resource, along with some great laughs and maybe a few tears – great memories were made.

Since then, many more state Medicaid programs have implemented the requirement to apply diagnosis codes to the ADA Dental Claim. Another fun fact, Glenda and I kept a white board and would add states and plans with the diagnosis code reporting requirement as we were able to confirm the information. Dr. Blair would come to our office after traveling to check the white board every Monday morning to see if we had added to the list. He would be so excited and as he used to say, “girls, we’ve hit a home run with this book!” Dr. Blair would be so excited and his heart fulfilled with every publication whether it be a single article or book knowing another dentist or dental team had a resource to help navigate their challenge.

Additionally, some dental plans have implemented the requirement of ICD-10-CM codes on dental claims. These plans include but are not limited to the Affordable Care Act medical plans with federally mandated pediatric preventive dental benefits, Medicare Advantage plans, and some plans that require a diagnosis code for specific procedures such as bone grafting. The requirement to apply diagnosis codes on dental claims is plan-specific and may sometimes be payer-specific. We have seen a steady increase in plan requirements since 2014 and expect this trend to continue.

While you may not be aware of a requirement to apply a diagnosis code to a dental claim, there may be times when you gave up on getting a claim processed, such as an ACA medical plan claim. Failure to apply diagnosis codes may have been the reason for claim rejection. I see this often.

So, what about the 2024 ADA Dental Claim Form changes? Yes, there were changes, and they were great ones, in my opinion. To learn more about these revisions, read my blog article here.

Another myth I am hearing is that effective May 1, diagnosis codes are required on the ADA Dental Claim Form. At least one dental payer I know of sent a letter to providers stating that effective May 1, 2024, if the claim was not submitted using the 2024 ADA Dental Claim Form, then your claim would be rejected. You see, a clean claim begins with the current claim form. A clean claim must be submitted to a payer, whether a medical or dental payer, to be adjudicated or processed. While most payers will grant a grace period and continue to accept the 2019 ADA Dental Claim Form, don’t be surprised if your claim is rejected in the near future if not submitted using the 2024 ADA Dental Claim Form. To be clear, just because a payer may require submission of claims using the 2024 ADA Dental Claim Form does not mean the payer requires application of ICD-10-CM codes. Contact your software vendor and clearing house to inquire about their readiness to implement the 2024 claim form for a smooth transition. Some practice management software may not be ready to implement the 2024 ADA Dental Claim Form. Your software support team can assist you in updating to the most current form.

In Conclusion

How can you best be prepared? Evaluate your documentation and improve on it. While you may not be required to submit a diagnosis code with your dental claim yet, we are held accountable for the same level of specificity in our documentation as if we are. Specificity in our clinical documentation is crucial, whether in a payer audit, court of law or claims adjudication. We must prove medical necessity –why a procedure is required. Let’s face it, patients don’t just drop in to see us and bring us brownies; they come for a reason, even for routine preventive dental care – and there is a code for that!

While we have discussed reimbursement in this article, it is not always about the reimbursement. It is about ensuring quality patient care. We do this by reporting ICD-10 codes along with our documentation. Be proactive and prepare for the need to apply a diagnosis code by reviewing your clinical documentation for specificity, implementing internal documentation audits involving your team, investing in education, and developing policies and procedures to ensure accuracy in documentation and reporting. As with all code sets, only what is documented can be reported! Documentation is key! If you want to learn more about diagnosis coding, join one of our workshops soon or reach out to inquire about our customized training for you and your team.