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CBCT Coding, Dental and Medical Billing, and Strategies for Profitability

Cone Beam Computed Tomography (CBCT) technology provides doctors with highly accurate images of the oral structures (anatomical positions of the teeth, soft tissue, and bones), allowing improved diagnosis and treatment planning. Cone Beam CT scanning technology with 2D or 3D renderings enables the doctor to “see” critical anatomic structures for implant placement, oral surgery, orthodontic, periodontal, endodontic, and TMJ procedures.

CBCT is a relatively new 3D imaging technology adopted by practices that provides a method to evaluate the anatomical positions of teeth and the makeup of the bone in a 3D image. An imaging unit (similar in size to a panorex machine) has an arm that revolves around the patient’s head in about 20 seconds. The CT acquires the axial, coronal, and sagittal data. The patient is exposed to radiation as the data is collected. An actual image is not produced. The data is captured and is stored, collated, and compiled into a 2D or 3D data pack. This data may be retrieved, assimilated, and viewed at a later time.

CBCT Guidelines for Dentistry

The patient is exposed to radiation during any radiographic procedure. A CBCT should be performed only when necessary to provide clinical information that cannot be obtained using other imaging modalities. The FDA’s Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging states imaging professionals are advised to follow the principles of justification and optimization to protect their patients.

Radiation doses from dental CBCTs are usually lower than other types of CT evaluations. However, dental CBCTs typically deliver more radiation than other conventional digital dental imaging modalities. Doctors must justify each radiographic examination on an individual needs’ basis, and the patient benefit of each exposure must outweigh the risks.

The American Dental Association (ADA) outlines guidelines related to the use of CBCT by dental professionals in “The Use of Cone-Beam Computed Tomography in Dentistry: An Advisory Statement from the American Dental Association Council on Scientific Affairs,” as published in the August 2019 edition of The Journal of the American Dental Association (JADA).

This article outlines a complete set of protocols that should be followed by dental practitioners when administering CBCT. For example, CBCT operators must receive “appropriate training and education in the safe use of CBCT imaging systems” and are encouraged to take continuing education classes to remain up to date on radiation protection.

Additionally, all federal and state laws relating to dental imaging must be followed when operating a CBCT, and all imaging systems should regularly undergo compliance and performance testing. These quality control checks measure radiation control levels to ensure patient doses are kept as low as possible.

When ordering a CBCT scan, the professional must use judgment to assess the current clinical situation and the necessity of the CBCT image. The CBCT should be interpreted by an “appropriately qualified healthcare provider,” such as a dentist, and the findings communicated to the patient and properly documented in the patient record.

Dental practices should establish quality control programs to ensure all these protocols are being met. For the ADA’s detailed analysis of CBCT, visit http://jada.ada.org/ and search CBCT.

Benefits of CBCT

CBCT images are useful in the diagnosis, treatment planning, and evaluation of various dental-related conditions. Since fewer images are needed for diagnosis, a single scan often provides the doctor with sufficient diagnostic information. More appropriate treatment recommendations are possible when patients are properly diagnosed.

The American Academy of Oral and Maxillofacial Radiology (AAOMR) has determined that a CBCT should be produced and reviewed prior to surgical implant placement to help reduce potential risks. CBCT images are also often used to evaluate impacted third molars located close to nerves or other structures, or for analyzing temporomandibular joint (TMJ) abnormalities or pathologies. Furthermore, CBCT images can also be used for the fabrication of surgical guides and cleft palate assessment. CBCT also aids in assessing endodontic and orthodontic conditions, cracked teeth, periapical pathology, and hard and soft supporting periodontal structures leading to improved clinical outcomes.

As more practices incorporate the use of CBCT, this technology has the potential to improve treatment outcomes, predictability, and to reduce the need for exploratory procedures, increasing the overall quality of care. While the initial cost of incorporating CBCT equipment is high, there is long-term potential for time savings.

Dental Coding For CBCT

Proper Code on Dental Procedures and Nomenclature (CDT) coding to report CBCT and related services is determined by four variables: 1. Who captured the data/performed the scan? 2. Who viewed and interpreted the image(s) that were produced by the CBCT? 3. What area of the head, neck, or body was captured by the CBCT? 4. What type of image was produced by the data captured (2D, 3D, fused, used in a simulation, or a subtraction process)?

There are multiple codes to report several unique uses for CBCT, as outlined below. Note that CBCT codes are categorized by whether the prescribing doctor captures the image, interprets the image, or does both. The appropriate CDT code may also be determined by the position and size of the image produced and interpreted.

The following codes describe the capture and interpretation of CBCT images:

D0364 Cone beam CT capture and interpretation with limited field of view – less than one whole jaw

D0365 Cone beam CT capture and interpretation with field of view of one full dental arch – mandible

D0366 Cone beam CT capture and interpretation with field of view of one full dental arch – maxilla, with or without cranium

D0367 Cone beam CT capture and interpretation with field of view of both jaws; with or without cranium

D0368 Cone beam CT capture and interpretation for TMJ series including two or more exposures

The following codes describe the CBCT image capture only (no interpretation):

D0380 Cone beam CT image capture with limited field of view – less than one whole jaw

D0381 Cone beam CT image capture with field of view of one full dental arch – mandible

D0382 Cone beam CT image capture with field of view of one full dental arch – maxilla, with or without cranium

D0383 Cone beam CT image capture with field of view of both jaws, with or without cranium

D0384 Cone beam CT image capture for TMJ series including two or more exposures

The following code describes the CBCT image interpretation only:

D0391 Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report

The following code describes the postprocessing of images:

D0393 Treatment simulation using 3D image volume

The use of 3D image volumes for simulation of treatment including, but not limited to, dental implant placement, orthognathic surgery, and orthodontic tooth movement.

When cone beam technology is used to produce a 3D image, that image may be used to simulate treatment. D0393 may be used to report a 3D image to simulate implant placement by demonstrating where the implant should be placed to avoid critical oral structures. CBCT technology allows the doctor to virtually place implants into the 3D image to evaluate the size, position, and angulation best suited for the unique application, and to identify and avoid any obstacles that may exist (nerves, blood vessels, or any other anatomy that must be avoided).

Placing implants, appliances, and other prosthetic devices in the 3D image allows a dentist to assess the placement of the appliance in relation to the inferior alveolar nerve or maxillary sinus. This type of imaging can also evaluate the osseous structure of the TMJ region. While it has many applications, the CBCT image is the ultimate diagnostic tool for implant dentistry as the bony architecture and bone density of edentulous spaces can be clearly assessed. In addition, the 3D image provides the doctor with additional information about the position and location of structures that may be impacted during orthognathic surgery, therefore optimizing the end result while minimizing the possible risks by avoiding vital structures.

A CBCT may be used to demonstrate soft tissue details of the skin surface in relation to underlying bony anatomy or to demonstrate muscles of mastication from MRI images in relation to their points of insertion in the jaws and surrounding tissues. In addition, orthodontists may use 3D images to optimize the results of the appliance and/ or implant anchorage placement.

D0394 Digital subtraction of two or more images or image volumes of the same modality

To demonstrate changes that have occurred over time.

D0395 Fusion of two or more 3D image volumes of one or more modalities

D0395 reports the use of cone beam technology to fuse two or more images or image volumes. The “hybrid layered” image can be used to evaluate the differences between the images or image volumes. Examples of use include precise registration of photographic images to cone-beam CT volumes or the fusion of CBCT/CT volumes to MRI volumes to simultaneously demonstrate soft tissue and hard tissue anatomy.

By systematically adding (D0395) or removing (D0394) selected images or image volumes from the “hybrid layered” image, the doctor can more accurately assess changes in the structures that may have occurred over a period of time. This data is particularly essential when determining the

progression of periodontal disease, the growth or reduction in the size of a lesion, or the status of site healing after surgery.

These processes may also be used to illustrate changes during growth or subsequent to treatment. Furthermore, these processes can be used to evaluate changes in facial appearance or jaw position and for the measurement of airway changes following the placement of a mandibular advancement device to treat sleep apnea. Fusion can also be used to merge optical images to CBCT and images of the skin surface to CBCT, MSCT, or MRI volumes to create higher resolution and avoid radiographic artifacts.

If CBCT technology is used to generate 3D images, report the applicable CBCT code. Smaller images such as periapicals (PAs), bitewings (BWs), or panoramic images (pans) can also be derived from the 3D data captured by CBCT technology. When this is the case, report the CBCT code that best describes the capture and request an alternate benefit of the image(s) produced in the narrative. It is important to note that it is considered unbundling to separately report the various images produced by the CBCT data capture.

Most current CBCT units can be set to capture 2D images and bypass the 3D capture capabilities. In other words, most CBCT systems can produce individual images of varying configurations without using their full 3D capabilities. If 2D images are produced, these images are reported by the correlating conventional radiographic image codes. For example, submit D0330 to report a panoramic image produced by standard or digital panoramic methods when the CBCT machine’s 2D setting is used. (Remember, if the imaging system is set to capture 3D data, CBCT codes should be reported.) Report what you do, regardless of insurance benefits, or lack thereof.

Reimbursement for CBCT Images

Reimbursement for Cone Beam CT’s is highly variable. Cone Beam CT is not generally reimbursed by dental. A Cone Beam CT may be submitted to medical as primary for reimbursement consideration subject to medical provisions. Documentation is essential. The clinical record must include the need for the CBCT, the field of view captured, and the interpretation of the image(s). Accurate, complete, and legible clinical documentation is the best tool available to establish medical necessity. Thorough documentation proving medical necessity will raise consideration for reimbursement.

Regarding dental coverage, the reimbursement of a specific procedure is based on the dental plan design. Periodic dental radiographs, such as bitewing radiographic images taken routinely, are reimbursed and may or may not be associated with a specific dental procedure being performed. Thus, the clinical documentation must clearly support dental/medical necessity and meet the payer’s established criteria for reimbursement. Generally, CBCT scans are not covered by most dental plans, thus the patient would be responsible for payment.

Medical coverage for CBCT varies by the medical plan. When possible, medical benefits should be verified prior to treatment. Some plans require prior authorization for CBCT imaging. Coverage by medical plans will be based on the diagnosis, or reason, for the CBCT scan and will not be covered for routine scanning for abnormalities.

While medical plans do contain exclusions, coverage is based on proven medical necessity. An example of a typical exclusion (as it applies to dentistry) is that most medical plans specifically exclude dental implants from coverage, unless medically necessary due to trauma. Additionally, some medical plans may contain language that excludes dental restorations due to trauma when the affected tooth does not meet the plan’s definition of a naturally sound tooth (i.e., existing crown, decay, etc. prior to the trauma). As an example, if implants are excluded, then the CBCT associated with the implant would also be excluded.

Generally speaking, a medical plan may consider reimbursement for CBCT when: (1) medical necessity is proven and (2) the associated dental procedure is deemed a covered service. For example, if the medical plan covers dental implants, then the CBCT required prior to implant placement may be considered. If the medical plan excludes coverage for dental implants, then the CBCT associated with the implant procedure is not likely to be reimbursed. Even if the patient’s plan includes

benefits for implants, coverage will be based on clinical necessity. The patient’s clinical record must clearly document the need for the CBCT, the field of view captured, and the interpretation of the image(s). Documenting all this information will help with reimbursement efforts for CBCT.

Certain payers, such as Medicare, require National Imaging Association credentialing to prove the practice has implemented safety protocols and precautions for radiation exposure. This credentialing helps ensure the technology is being properly utilized. Adding CBCT technology to an existing contract is often a quick process and is well worth the effort for some practices.

Circumstances when CBCT may be covered include: § Impacted third molars positioned close to the inferior alveolar nerve § Proposed implant placement close to the inferior alveolar nerve or maxillary sinus § Proposed implant placement where there may be inadequate bone § TMJ abnormalities/pathology § Reconstructive or cosmetic surgery due to trauma or birth defects

Medical Billing for CBCT

Medical billing requires BOTH procedural and diagnosis codes. Unlike dental billing, which is primarily reported by the procedure code, medical billing is typically determined by the diagnosis or symptom reported. In other words, it is imperative to tell medical payers WHY you took the CBCT, not just that it was taken. This is done using ICD-10-CM codes.

Medical Diagnosis Coding

The ICD-10-CM diagnosis code(s) reported must report the patient’s condition and the necessity of service. Never report a procedure or diagnosis code just because “someone told me this is how to be paid.” This is considered fraudulent billing by both dental and medical payers. Medical payers will reimburse for legitimate, covered services when submitted correctly and the criteria for medical necessity are met and documented. Only those conditions supported by the medical documentation should be submitted. Examples of possible diagnoses codes include, but are not limited to: K01.0 Embedded teeth (soft tissue impacted) K01.1 Impacted teeth (bony impacted – partial or full) K08.4049 Partial loss of teeth, unspecified cause, unspecified class K08.439 Partial loss of teeth due to caries, unspecified class K08.429 Partial loss of teeth due to periodontal disease, unspecified class K08.401 Partial loss of teeth, unspecified cause, class I M26.4 Malocclusion, unspecified M26.611 Adhesions and ankylosis of right temporomandibular joint M26.612 Adhesions and ankylosis of left temporomandibular joint M26.631 Articular disc disorder of right temporomandibular joint M26.632 Articular disc disorder of left temporomandibular joint M26.69 Other specified disorders of temporomandibular joint S09.93XA Injury to mouth, initial encounter G47.33 Obstructive sleep apnea (adult) (pediatric) G47.63 Sleep related bruxism

Again, this is a small representation of the available codes in the ICD-10-CM code set. Please refer to our book Medical Dental Cross Coding with Confidence for a comprehensive set of dentalrelated codes and how to report them. Copies are available at www.practicebooster.com/store.

Medical Procedural Coding

Corresponding Current Procedural Terminology (CPT®) medical codes for CBCT images are designed for the capturing and interpretation of images unless a modifier is attached to the CPT code communicating to the payer that it was a capture only or interpretation only. These codes are as follows:

70486 Computed tomography, maxillofacial area; without contrast material (when 3D imaging is performed, also report the appropriate code listed below)

76376 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation 76377 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation 76380 Computed tomography, limited or localized follow-up study Note: CPT code 70486 reports the image capture and interpretation only. When 3D imaging is performed, it is reported with either CPT code 76376 or 76377.

If only the image capture or interpretation is provided, use the appropriate modifiers to assign to the above CPT codes as listed below: • TC Technical component (i.e., image capture only) • 26 Professional component (i.e., interpretation only)

If the same dentist reports both the image capture and the interpretation, no modifier is required, as noted above.

Strategies for Maximizing CBCT Profitability

Frequently, CBCT scans are not a covered benefit by either dental or medical payers. That said, it is usually denied but not disallowed by PPO payers. That means the office fee or adjusted PPO fee can be passed on to the patient. An adjustment may be necessary depending on the state in which you practice.

To get the most out of your CBCT, it is a better strategy to attach a lower, more accessible, cost to the procedure than a high one. Simply put, it is better to do 100 CBCT images at $100 each than to try and do 20 at $500 each. This improves the odds of case acceptance and allows the provider to access the data and imagery required to perform services with the highest quality of care.

By definition, each exposure is considered one radiograph. Therefore, relying on software to simulate and extract different views, while possible, is not a separate billable fee. You cannot extract a panoramic view out of a 3D exposure and bill for both the 3D exposure and the panograph image. If you choose to use your CBCT to take panoramic radiographs, you may opt to bill using code D0330, which may be paid for through the patient’s dental plan, and then not bill for the CBCT scan.