Billing for Extra Time Needed to Treat Individuals with Special Needs

Allen Wong, DDS, EdD, has taught postdoctoral general dentistry for over 35 years in AEGD programs in the Bay Area, is the director of the University of the Pacific, Arthur A. Dugoni School of Dentistry’s hospital dentistry program and was the director of the Highland Hospital restorative implant program. He has lectured nationally and internationally in the areas of special care dentistry, rotary endodontics, implant restorations and minimally invasive dentistry. Conflict of Interest Disclosure: None reported.

Ellen Darius, RDH, MS, MPH, received her BS and MS in dental hygiene from the University of California, San Francisco. She spent several years as a dental hygienist in private practice and served as assistant clinical professor at the UCSF School of Dentistry. She participated in several research studies and received her MPH from UC Berkeley. She is passionate about increasing access to dental care for individuals with disabilities. Conflict of Interest Disclosure: None reported.

The goal of health care is that it should be fair, respectful and inclusive for all individuals. The population of those with medical, physical, behavioral or developmental conditions is increasing in their lifespan and comorbidities. There are multiple barriers to accessing dental care for this population. When care is attained, it is often for severe dental needs requiring hospital dentistry. The obvious strategy to lessen costly outcomes is prevention. However, dental providers may be hesitant to provide preventive treatment to individuals with special needs because of the extra time required for these services. A new code, CDT Code D9920, was introduced that allows providers to be compensated for the extra time required to provide preventive care to this underserved population. While this billing code has been in effect for over two years, many dental providers are not using this code or are not being reimbursed because of insufficient documentation. If used correctly, this code provides a financial incentive of $140 up to four times per year. The purpose of this article is to offer guidance to practitioners as to how and when to use this code and encourage providers to begin accepting individuals with special needs.

Code D9920 was established for “behavioral management” to help accommodate for the extra time necessary to properly treat patients with special needs. Behavior management, defined as a process by which dentists can help clients identify appropriate and inappropriate behavior, learn problem-solving strategies and develop impulse control, empathy and self-esteem, can be an effective alternative to costly and invasive procedures. When employed appropriately, behavior guidance results in more positive attitudes toward dentistry and lays the foundation for a lifetime of positive oral health experiences. Documentation must indicate specific techniques applied according to the individual client’s needs. This ensures that dental records include information on techniques that result in successful outcomes and aids providers in reproducing positive dental experiences for clients at future visits.

With all billing codes, a concern for fraud is always present. Therefore, documentation of why extra time is needed is important along with a “billable” procedure. Code D9920 for behavior management allows usage of four times per year with a procedure code and documentation of post treatment.

According to AB-316 Medi- Cal: benefits: beneficiaries with special dental care needs:

“That documentation shall include the medical diagnosis of a patient’s condition, a description of additional steps undertaken by the provider in their attempt to successfully treat the patient, and the reason for the need of additional time for a dental visit.”

Instructions for D9920 Use

■ Behavior Modification (D9920) is only payable for clients with special needs requiring additional time for dental treatment.

■ Behavior Modification (D9920) is not payable when sedation is used as a behavior modification modality. This code cannot be combined with the use of nitrous oxide, oral sedation or general anesthesia. In these cases, it can be used if a provider chooses not to bill for sedation.

■ When properly used, D9920 allows for payments of $140 for up to four visits in a 12-month period.

■ The code cannot be used alone; it must be used in conjunction with other services that are billable, even if it is just combined with fluoride varnish or radiographs.

■ Written documentation for payment shall include documentation that the client has special needs that require additional time to complete treatment. Special needs clients are defined as those who have a physical, behavioral, developmental or emotional condition that prohibits them from adequately responding to a provider’s attempts to perform a dental visit.

■ Documentation must include a medical diagnosis. This diagnosis does not need to be a formal written diagnosis from a medical provider. It can be confirmed by a parent or caregiver.

■ Custom documentation must include the reason for the need of additional time for a dental visit. The patient’s diagnosis alone is not sufficient documentation, and these claims will be denied. For example, a provider should not indicate “extra time was needed because the client is autistic” or “extra time was needed because the client is in a wheelchair.” A more detailed description is necessary. For example, “the client experiences ataxic movements due to cerebral palsy, requiring extra time for adequate placement of the X-ray sensor,” or “due to partial paralysis of the neck, the client is unable to tilt their head back requiring extra time to adequately clean the maxillary arch.”

Bringing It All Together

The new code is applicable in conjunction with a “billable procedure(s)” in a clinical setting and not meant for solely “observation” or desensitization visits. Once cleanings and fillings are completed, there is a good opportunity to engage the patient in a “proactive prevention” program. One of the most important concepts in medicine and dentistry is an accurate diagnosis. Dentistry has been too focused on fixing problems versus preventing disease.

With minimally invasive techniques such as silver diamine fluoride, partial caries removal concepts and remineralizing strategies, we can help reduce rates of active caries, the need for extensive dentistry and in some cases, reduce the need for hospital dentistry. Each procedure mentioned can be a “procedure” used with the behavior management code, if warranted.

Caries risk assessment along with periodontal risks should always be diagnosed, treated and monitored for progress or decline. We cannot treat what we do not diagnose.

It is imperative to have an accurate caries risk assessment to help justify the additional need for more appointments to support a prevention-based program and help improve the patient’s health. In doing so, we can avoid premature and unnecessary extractions and improve quality of health and life. Having less teeth to function can create a domino effect toward eating efficiency, gastrointestinal problems, social stigma and self-esteem. Along with a documented medical necessity, it also makes sense that there is a documented dental necessity. If properly documented, additional appointment intervals should be considered for which use of the D9920 code might not only be justified but appropriate.

Being fairly compensated for the additional time taken to treat patients who need who need behavioral support while receiving their needed and preventive treatment is truly an inclusive concept. If dental providers who accept clients enrolled in Medi- Cal can successfully bill for behavioral management, it will increase access to care for individuals with special needs.

Individuals with special needs face numerous barriers in obtaining dental care. The lack of preventive care often results in severe dental needs requiring hospital dentistry. Providers may be hesitant to accept these clients because of the extra time required for their treatment. Including behavior modification and guidance techniques to your dental treatments can help individuals with special needs tolerate treatment and form positive dental experiences. The behavior modification code D9920 provides a financial incentive for dentists to allow for the time necessary to provide this critical service.

Readers can read the actual wording for the AB-316 Medi-Cal benefit here.

THE CORRESPONDING AUTHOR, Allen Wong, DDS, can be reached at awong@pacific.edu.