Session 40 L, Diagnosis Coding in Dental. Presenter: Thomas Daniel Murawski, FSA, MAAA. SOA Antitrust Disclaimer SOA Presentation Disclaimer

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1 Session 40 L, Diagnosis Coding in Dental Presenter: Thomas Daniel Murawski, FSA, MAAA SOA Antitrust Disclaimer SOA Presentation Disclaimer

2 Diagnosis Coding in Dental Society of Actuaries 2017 Health Meeting Session 40 June 12, 2017 Thomas Murawski, FSA, MAAA

3 Session Goals To understand: Current state of dental diagnosis coding Efforts underway to create a standardized diagnosis code set The potential for better analysis once these codes are implemented 2

4 The single, largest current limitation in dental clinical data is the lack of consistent, standardized, and widespread reporting of dental diagnoses. Dr. Jill Boylston Herndon 3

5 History of Diagnosis Coding Purpose, coding systems

6 Different types of codes Procedure codes Services performed on patient Examples: CPT, HCPCS, CDT codes Diagnoses codes Symptoms or diagnoses associated with services Supports medical necessity for the service Example: ICD codes Together provide comprehensive and complete picture of claim Source: Fontana, J. Dental Diagnosis Coding: The State of the Art 5

7 Diagnosis coding A standardized system by which diseases, disorders, injuries and other medical problems may be classified Informs patient treatment plans, claims payment, development of clinical best practices, and population risk assessment and adjustment Code describes patient s diagnosis, symptom, condition, or complaint No such standard has existed for dental care Source: Fontana, J. Dental Diagnosis Coding: The State of the Art 6

8 Evolution of diagnosis coding 1600s: England developed basic medical coding to classify mortality rates by cause. London Bills of Mortality: data gathered through this system and arranged into numerical codes used to measure most frequent causes of death Evolved through 1800s - better classifications Epidemic General Local according to anatomical site Developmental 1885 English/German/Swiss group to adopt classification system Bertillon Classification of Causes of Death first to receive approval and adoption by several countries including North America Source: Fontana, J. Dental Diagnosis Coding: The State of the Art 7

9 Evolution of diagnosis coding 1937: statistical analysis of causes of death organized into the International List of Causes of Death Later developed into the International Classification of Diseases (ICD-10) maintained by World Health Organization 1977: National centers for Health Statistics expanded the system to include clinical information (illnesses and injuries) Source: 8

10 Evolution of diagnosis coding Several evolutions, led to internationally adopted lists World Health Organization International Statistical Classification of Diseases, Injuries, and Causes of Death (ICD) Level of sophistication improved and uses of diagnosis codes expanded to track clinical diagnoses and not just causes of death. National Center for Health Statistics developed adaptation of ICD-10 ICD-10-CM - clinical modification focus on morbidity rather than mortality ICD-10 US adoption date October 2015 ICD 10 is HIPAA standard diagnostic code set for use in electronic transactions Source: Fontana, J. Dental Diagnosis Coding: The State of the Art 9

11 History of procedure coding Procedure coding practices are newer than diagnosis codes Current Procedural Terminology (CPT) coding manual provides descriptions of healthcare services CPT codes developed by American Medical Association in : Center for Medicare and Medicaid services adopted CPT system (HCPCS) Source: 10

12 History of procedure coding HCPCS Healthcare Common Procedure Coding System Developed in 1983 by CMS Standardize coding system for services and supplies Based on CPT codes HCPCS = CPT code + Level II code for nonphysician services (ambulance, supplies, medical devices) + Level III code developed by Meciare contractors, state Medicaid organizations, private insurers Level III discontinued in 2003 Source: Fontana, J. Dental Diagnosis Coding: The State of the Art 11

13 Dental Diagnosis Coding Current Status

14 Current state of dental procedure coding CDT (Current Dental Terminology) committee comprised of ADA, dental providers, payer and professional organizations designated by federal government as the national terminology for reporting dental services on claims submitted to third party payers CDT is the only HIPAA compliant code set for reporting dental procedures Diagnosis sometimes embedded in CDT code itself via difficulty descriptors, actors D1352 preventive resin restoration in moderate to high risk caries patient D2983 veneer repair necessitated by restorative material failure New for 2017 Scaling in presence of generalized moderate or severe gingival inflammation full mouth, after oral evaluation Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure But not a comprehensive diagnosis coding tool Source: Fontana, J. Dental Diagnosis Coding: The State of the Art 13

15 Dental Data - Composition Dental procedure codes follow a uniform code type ADA Codes CDT Codes - D Codes DXXXX Hundreds of different codes % Of Total Cost Number of Codes 50% 10 90% 40 95% 60 Source: Milliman s Health Cost Guidelines - Dental

16 Dental Data Top 20 Codes By Billed Charges PMPM, Sorted by Code Description Periodic oral evaluation - established patient Limited oral evaluation - problem focused Comprehensive oral evaluation - new or established patient Intraoral - complete series of radiographic images Bitewings - four radiographic images Panoramic radiographic image Prophylaxis - adult Prophylaxis - child Resin-based composite - one surface, posterior Resin-based composite - two surfaces, posterior Resin-based composite - three surfaces, posterior Crown - porcelain/ceramic substrate Crown - porcelain fused to high noble metal Crown - porcelain fused to predominantly base metal Crown - porcelain fused to noble metal Endodontic therapy, molar (excluding final restoration) Periodontal scaling and root planing - four or more teeth per quadrant Periodontal maintenance Extraction, erupted tooth or exposed root Surgical removal of erupted tooth Category I-Oral Evaluations I-Oral Evaluations I-Oral Evaluations I-X-Rays I-X-Rays I-X-Rays I-Prophylaxis I-Prophylaxis II-Restorations II-Restorations II-Restorations III-Inlays/Onlays/Crowns III-Inlays/Onlays/Crowns III-Inlays/Onlays/Crowns III-Inlays/Onlays/Crowns II-Endodontics II-Periodontics II-Periodontics II-Simple Extractions II-Surgical Extractions Source: Milliman s Health Cost Guidelines - Dental

17 Diagnosis coding systems in dentistry ICD (International Classification of Diseases) SNODENT EZ Codes/DDS 16

18 Dental Diagnosis Coding ICD

19 Structure of ICD-9 vs. ICD-10 Length: 3-5 digits First character: # or letter E or V Characters 2-5: # Minimum length: 3 characters Decimal: After 3 rd character Length: 3-7 digits First character: All letters except U Characters 2: # Characters 3-7: # or letter Decimal: After 3 rd character Letter format: Case-sensitive Source: CDT 2017 (ADA) 18

20 ICD-9 CM sample codes Source: CDT 2017 (ADA) 19

21 Mapping from ICD-9 to ICD-10 Source: CDT 2017 (ADA) 20

22 ICD-10 CM sample codes Source: CDT 2017 (ADA) 21

23 ICD-10 CM sample codes K Codes Diseases of Oral Cavity and Salivary Glands (K00-K14) K00 Disorders of tooth development and eruption K01 Embedded and Impacted teeth K02 Dental Caries K03 Other diseases of hard tissue of teeth K04 Diseases of the pulp and periapical tissues K05 Gingivitis and periodontal diseases K06 Other disorders of gingiva and edentulous alveolar ridge K08 Other disorders of teeth and supporting structures (incl. Loss of teeth) K09 Cysts or oral region, not classified elsewhere K11 Diseases of salivary glands Source: National Network for Oral Health Access 22

24 ICD-10 CM sample codes M Codes Diseases of the musculoskeletal system and connective tissue M26-M27 Dentofacial anomalies [including malocclusion] and other disorders of jaw M26.6_ TM joint disorders M26.62 Anthralgia M27.3 Alveolitis of jaws M27.5_ Periradicular pathology assoc. with prev. endodontic treatment M27.6_ Endosseous failure of dental implant M27.62 Post-osseointegration biological failure of dental implant (lists reasons including poor OH) Source: National Network for Oral Health Access 23

25 ICD-10 CM sample codes Combination Codes for Commonly Associated Symptoms and Manifestations Ex: Diabetes associated with periodontitis E Diabetes mellitus due to underlying condition with periodontal disease E Diabetes mellitus Type 1 with periodontal disease E Diabetes mellitus Type 2 with periodontal disease 3 Source: National Network for Oral Health Access 24

26 Medicaid and ICD codes Some state Medicaid programs require ICD codes on dental claim forms Validate recipient gets enhanced benefits or has a chronic condition that requires dental services 2015: Only NV required ICD codes on every Medicaid dental claim Source: Fontana, J. Dental Diagnosis Coding: The State of the Art 25

27 Diagnosis coding in Medicaid STATE MEDICAID Arizona Iowa Maine Michigan Nevada Vermont Requirements Diagnosis code(s) required when the patient s underlying medical condition is the reason for the services provided on the claim. V22.2 (Pregnancy) and V49.89 (Disabled) must be reported whenever a patient has either of these conditions, regardless of services provided. Note that Iowa is still accepting the 2006 claim form and there is no cutoff date planned at this time. Diagnosis code required on dental claims for procedure code D4341 for all patients whose diagnosis is ICD-9 code 101 (Acute Necrotizing Ulcerative Gingivitis) or ICD-10 code A69.0 (necrotizing ulcerative stomatitis) or A69.1 (other Vincent s infections). For patients with no ICD-9 code 101 or ICD-10 codes A69.0 or A69.1 diagnosis, claims for this procedure code require Prior Authorization. Diagnosis codes are required for all oral and maxillofacial surgery and/or anesthesiology services New 2012 ADA form with valid diagnosis codes, diagnosis pointers and place of treatment. Will not require reporting of ICD codes until October 1, 2015 at the earliest. Source: ADA 26

28 Dental Diagnosis Coding SNODENT

29 Diagnosis coding systems in dentistry Systemized Nomenclature of Dentistry (SNODENT) Currently owned by ADA Development began in 1990s, first release in 2012 Source: National Network for Oral Health Access 28

30 SNODENT Official subset of SNOMED CT Owned by International Health Terminology Standards Development Organisation ( IHTSDO ) Standardized terms for describing dental disease, captures clinical detail and patient characteristics Interoperable with EHR and EDR Allows analysis of patient care services and outcomes SNODENT ~7000 codes SNODDS~1500 codes for use in EHR user interfaces SNODDS GD ~300 codes tailored for general dentist for use in EHR interfaces Other subsets being created (SNODDS OS) Source: 29

31 History of SNODENT SNODENT (~7,000 codes) Systemized Nomenclature of Dentistry Comprehensive clinical terminology for Dentistry that includes diagnosis, findings and anatomy SNODDS (~1,500 codes) Comprehensive Dental Diagnostic Terminology for use in EHR user interfaces SNODDSGD (~300 codes) Diagnostic Terminology tailored for the General Dentist for use in EHR user interfaces Source: National Association of Dental Plans Impacts of Diagnostic and Procedure Coding on the Dental Industry 30

32 SNODENT Early adopter stage 71% of US dental schools are using a standardized documentation of diagnosis in EHR Several DSOs working with public programs and research have also incorporated VA, some DMOs adopting FQHCs use SNODDS to convert to ICD for payment Crosswalks to match to ICD10 Payers capturing and aggregating diagnosis codes Source: 31

33 Dental Diagnosis Coding EZ

34 Diagnosis coding systems in dentistry EZ or DDS Codes (Dental Diagnostic System) Developed in 2009 by Consortium for Oral Health Research and Informatics (dental schools Harvard, etc.) Adopted by 15 dental schools Used in other institutions including some FQHCs Used in US and Europe Have been mapped to CDT, ICD9, ICD10, SNOMED 1300 codes Synchronized with SNODENT Providing SNODENT with a the full code set Allowing DDS to be used in provider interfaces as well as coordinated and unified standard for dental diagnosis coding. Source: National Network for Oral Health Access 33

35 History of SNODENT Source: National Association of Dental Plans Impacts of Diagnostic and Procedure Coding on the Dental Industry 34

36 Dental Diagnosis Coding Future Possibilities and Challenges

37 Internal uses of diagnosis coding Risk adjustment mechanisms Proper clinical protocols Develop best practices Track health and disease conditions Designing payment systems and processing claims for reimbursement Insurers use information to determine medical necessity and whether service should be covered Measure quality and efficacy of care Preventing and detecting healthcare fraud Source: National Network for Oral Health Access 36

38 External uses of diagnosis coding Data used to asses and track health trends and epidemics Conducting research, studies, and clinical trials Setting health policy Monitoring resource utilization Disease management programs Directs outreach Standard documentation and nomenclature across medical community Source: National Network for Oral Health Access 37

39 Impact of diagnosis coding risk adjustment E.g. Medicare Advantage plans are paid partially on risk adjusted basis, based on how sick the patient population is; ACOs as well Insurers measure acuity of a group of patients by age/gender and by diagnosis coding on claim forms Industry moving toward these payment mechanisms, thus capturing diagnosis more important Source: National Network for Oral Health Access 38

40 Practice patterns Identifying CDT codes that are markers for chronic periodontitis and ensuring high risk patients get the diagnostic and preventive services they need Ongoing periodontal care and frequent cleanings Topical fluoride for adults at elevated risk Diagnosis coding would support these analysis and allow for more targeted treatments and more efficient allocation of medical resources Source: National Network for Oral Health Access 39

41 Quality Measures Lack of standard and prevalent diagnosis coding is the biggest obstacle Related to improving treatment patterns If/when providers bear more risk quality measures are essential Source: National Network for Oral Health Access 40

42 Dental diagnosis coding challenges Cost to educate dentists and staff Payers who want to require codes will need to redesign platforms to accept them Over one year, UCSF students used only 7% of the 1300 EZ codes how to make relevant/simplify Chicken or egg problem Source: National Network for Oral Health Access 41

43 Moving forward Diagnosis codes promote progress in oral health We should embrace more data as actuaries Take time to become fully explored and implemented Education Enhanced information systems Changes to claims payment systems Areas of improvement: Dental benefits Claims payment and provider reimbursement Clinical practices and quality of care Outcomes and performances measurement Source: Fontana, J. Dental Diagnosis Coding: The State of the Art 42

44 Open Discussion

45 Caveats and limitations I, Thomas Murawski am an Actuary for Milliman. I am a member of the American Academy of Actuaries and meet the Qualification Standards of the American Academy of Actuaries to render the actuarial opinion contained herein. Milliman has prepared this presentation for the specific purpose of providing commentary on the diagnosis coding in dental. This information may not be appropriate, and should not be used, for any other purpose. No portion of this presentation may be provided to any other party without Milliman's prior written consent. Milliman does not intend to benefit or create a legal duty to any third party recipient of its work even if we permit the distribution of our work product to such third party. Milliman does not provide legal advice, and recommends that the SOA consult with its legal advisors regarding legal matters. This presentation was prepared solely for the Society of Actuaries for a discussion of dental diagnostic coding. Milliman does not intend to benefit and assumes no duty or liability to parties who receive this work. Milliman recommends that parties be aided by their own actuary or other qualified professional when reviewing this material.

46 Thank you Thomas D. Murawski (860) This presentation was prepared solely for the Society of Actuaries for a discussion of dental diagnostic coding. Milliman does not intend to benefit and assumes no duty or liability to parties who receive this work. Milliman recommends that parties be aided by their own actuary or other qualified professional when reviewing this material.