Oral health care is a vitally important service for children’s well-being, and coverage of dental insurance codes by both public and private insurers is key in ensuring access to comprehensive oral health care for children. This brief illustrates the importance and shows state coverage of key codes in improving access to oral health care as of 2020.
The American Academy of Pediatric Dentistry (AAPD) has a long history of promoting optimal oral health and oral health awareness for infants, children, adolescents and patients with special health care needs, as well as championing initiatives that have widened access to care for the nation’s youngest and most vulnerable populations. The AAPD works on both national and state levels to address barriers to care, such as affordability, parent oral health literacy, administrative burdens for payment and far-below-market reimbursement, and stronger investment in community-based initiatives providing care to underserved children.1 Federal and state governments are likely to reassess their level of commitment to providing dental care to the country’s most vulnerable populations in the years ahead, which provides a unique opportunity for increasing dental care coverage for those patients.
Advocacy for critical health care services for poor and underserved children is critical, particularly during this politically divisive time, and the AAPD’s vision of optimal oral health for all children necessitates the inclusion of effective diagnostic, preventive and restorative dental services in state Medicaid dental plans. This publication evaluates Medicaid coverage for a select group of insurance codes that address barriers to optimal oral health. These codes extend beyond traditional procedures most commonly covered by dental insurance plans to provide access-related services that protect the oral and total health for children. The goal of this analysis is to raise awareness of the existence of these procedure codes and the importance of advocating for their inclusion in state fee schedules. The selected codes represent a range of services that promote oral health, disease prevention and establishment of a dental home; mitigate the high demand for dental rehabilitation under general anesthesia; and address logistical and social barriers to care. They are discussed in two categories: Providing Essential Services for Oral Health and Addressing Barriers to Optimal Oral Health. The dental fee schedules for the 50 states and the District of Columbia were accessed online to ascertain whether the codes are covered.
The report of codes covered by individual states is current as of October 2020. During the time of writing, some services covered here may have been in the legislative process and not listed. To find the status of your state’s coverage for all codes, there is a table on pages 12-13. Many state Medicaid websites provide fee schedules illustrating most-recent coverage status for these codes and others. How are dental insurance codes created? The American Dental Association (ADA) first published in 1969 the Uniform Code on Dental Procedures and Nomenclature (Current Dental Terminology or CDT Codes) to appropriately identify, standardize and categorize dental procedures, which allows for efficient documentation and insurance claim submission.2 The Code Maintenance Committee is responsible for CDT code changes, and is composed of representatives of the ADA (Council on Dental Benefit Programs), Academy of General Dentistry and dental specialty organizations (including the AAPD), as well as several third-party payer organizations and the Center for Medicaid and Medicare Services (CMS).3 Why are insurance codes so important to children’s oral health care? The codification of procedures positively affects the delivery of oral health care in several ways.
First, communication: By assigning a code to a dental service, the dentist tells the insurance program – and the patient’s family – exactly what care was provided.
Second, awareness: The inclusion of a specific procedure code, as well as a description of the service in a state Medicaid provider manual, can serve to heighten awareness for that procedure and encourage its use. For example, providers who become aware of CDT Code D1320 (Tobacco Counseling) may be more likely to discuss tobacco cessation with patients because the code explicitly confirms that the service is within their scope of practice.
Third, financial clarity: Codifying dental procedures is essential to ensuring reimbursement to providers and managing provider expectations via contracted fee schedules.
Fourth, documentation of health outcomes: Procedure codification leads to more accurate patient recordkeeping and follow-up care. When providers can properly document completed treatment on a patient through a particular code, they are able to track the effects of the procedure more thoroughly and plan follow-up care. Furthermore, procedures can then be tracked via insurance claims data to verify what procedures work for different situations and diagnoses. Thus, this collection of data directly affects the availability of outcomes research. Fifth, health equity: Codification and record-keeping of dental services provide valuable data on the crucial disease factors related to social determinants of health. Analysis of service utilization and their respective effects will promote positive action to help eliminate disparities and inequities in our nation’s population.
Post time: Sep-26-2021