Dental Claims Requiring Use of ICD-10-CM Codes

by  Christine Taxin, President - Links2Success
Feb 12th, 2025

Dental claims now require the use of ICD-10-CM codes. Several states (e.g., Arizona) have begun to mandate that diagnosis codes be reported along with dental codes on claim forms. For instance, if a patient’s visit is due to an underlying medical condition, an ICD-10-CM code must be included. Additionally, government payers like BCBS Federal already require the use of diagnosis codes, and it is expected that other payers will adopt ICD-10-CM in the future. If you have specific questions about your state’s requirements or need further guidance, consider checking with your state Medicaid or commercial dental plans. 

Remember that dental offices typically use a subset of ICD-10-CM codes related to oral health, so it need not be overwhelming for your staff. Here are some relevant sections for dental providers:

K00-K14: Diseases of the oral cavity and salivary glands

K00.0-K00.9: Disorders of tooth development and eruption
K01.0-K01.1: Embedded and impacted teeth.
K02.3-K02.9: Dental caries
K03.0-K03.9: Other diseases of hard tissues of teeth
K04.01-K04.99: Diseases of pulp and periapical tissues
K05.00-K05.6: Gingivitis and periodontal diseases
K06.010-K06.9: Other disorders of gingiva and edentulous alveolar ridge
K08.0-K08.9: Other disorders of teeth and supporting structures.
K09.0-K09.9: Cysts of the oral region
K11.0-K11.9: Diseases of salivary glands
K12.0-K12.39: Stomatitis and related lesions
K13.0-K13.79: Other diseases of lip and oral mucosa
K14.0-K14.9: Diseases of the tongue

Remember, understanding these codes will support evidence-based benefit plans and enhance patient care management. If you need more information, feel free to ask!

Finding the right ICD-10-CM code for a specific condition involves a systematic process. Here are some steps to guide you:

1. 1. Identify the Condition: First, accurately diagnose the patient’s condition. Gather relevant information from the patient’s medical history, physical examination, and any diagnostic tests.
   2. Consult the ICD-10-CM Manual: Obtain a copy of the ICD-10-CM coding manual. You can find it online or in print. The manual contains a comprehensive list of codes organized by chapters, sections, and categories.
   3. Navigate to the Relevant Chapter: Each chapter in the ICD-10-CM manual corresponds to a specific body system or condition. Identify the chapter that best aligns with the patient’s diagnosis. For dental conditions, focus on Chapter 11 (“Diseases of the Digestive System”) and Chapter 12 (“Diseases of the Skin and Subcutaneous Tissue”).
   4. Locate the Specific Code: Within the relevant chapter, search for the specific condition. The codes are alphanumeric and follow a consistent format (e.g., K00.0, K01.1, K02.3). Pay attention to any subcategories or additional details provided under each code.
   5. Consider Laterality and Specificity: Some codes require additional specificity, such as laterality (left vs. right) or severity. Choose the most accurate code based on the available information.
   6. Use Additional Codes When Necessary: In some cases, you may need to use multiple codes to fully describe the patient’s condition. For example, if a patient has both dental caries and gingivitis, report both relevant codes.
   7. Check for Excludes Notes and Code First Notes: Excludes notes indicate conditions that should not be coded together. Code first notes provide guidance on sequencing codes (e.g., underlying condition vs. manifestation).
   8. Document the Code: Once you’ve identified the appropriate code, document it in the patient’s medical record and use it on claim forms for billing purposes.

Remember that accurate coding is essential for proper reimbursement, clinical decision-making, and statistical analysis. If you encounter any challenges or uncertainties, consult with colleagues, coding specialists, or refer to official coding guidelines.

Let’s explore an example of finding a specific dental code using the CDT (Current Dental Terminology) system. Dental codes help accurately document and bill various dental procedures. Here’s how you can find a code:

1. 1. Identify the Procedure: Suppose a patient has an abscess of the gums, which requires incision and drainage in your office.
   2. Navigate the CDT Code Manual:
      1. The CDT Code is published by the American Dental Association (ADA) and is updated annually. It provides a standardized set of codes for dental procedures.
      2. Each code consists of five alphanumeric characters (e.g., D7510).
   3. Search for the Relevant Code:
      1. In the CDT manual, look for the section related to oral evaluations and surgical procedures.
      2. Find the code that corresponds to incision and drainage of abscess of the intraoral soft tissue.
   4. Specific Example:
      1. The dental (CDT) code for this procedure is D7510.
      2. Note that the medical (CPT) code for the same procedure is 41800, so use the code that the payer wants on the claim.

What ICD-10-CM Code Should I Use for Dental Care?

Encounter for dental examination and cleaning without abnormal findings. Z01. 20 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2024 edition of ICD-10-CM Z01.

Why is this Happening?

The oral systemic issues and all Dental has now included Enhanced Benefits for Hygiene, so patients’ oral systemic issues will receive more care under the dental policy. Also, the medical world has issued a web site to teach medical providers because they need to collaborate with the dental world. Now is the time we need to change our perception of treatment since it is for the overall health of the patient.

Each state’s Medicaid and CHIP programs are continually evolving, with most states expanding coverage for low-income adults and modernizing their eligibility, enrollment, and renewal processes. These changes are often influenced by the Affordable Care Act. If you need more specific information about a particular state, feel free to ask!

Here’s what Horizon Dental has to say about the use of ICD-10-CM codes:

Remember that accurate coding ensures proper reimbursement and supports efficient claims processing. If you encounter any specific scenarios or need further assistance, consult the official CDT manual or seek guidance:  contact Christine Taxin at ctaxin@links2success.biz or go to www.dentalmedicalbilling.com and join our yearly membership program.