Question

Q: How is the use of Exparel® reported?

A: When injecting Exparel® or other non-opioid analgesia to control pain (for example, after an extraction)
report D9613 infiltration of sustained release therapeutic drug – single or multiple sites.

Q: What code reports the sale of an electric toothbrush?

A: There is no current CDT code to describe the sale of any consumer product. The practice might adopt an internal code, unique to the office, which tracks the sale of an electric toothbrush (or other products sold
by the practice). D1999 or D9999, by report could describe the sale of products. Check with your tax
professional for additional guidance regarding sales and sales tax reporting. In some cases, PPO contracts
require all charges to be reported to the PPO.

Q: What code is used to report tooth whitening refills?

A: D9999 should be used to report tooth whitening refills. (Note: D9975 states “includes materials” and does not specify when the refills are dispensed.)

Q: What code is used to report the smoothing of a chipped tooth at an emergency visit?

A: Consider reporting D9110, palliative treatment. Include a narrative describing the procedure and outlining the patient’s discomfort resulting from the chipped tooth.

Q: What code reports an additional fee for an after hours office visit?

A: Report D9440, office visit – after regularly scheduled office hours, in addition to any additional services
rendered.

Q: Can a consultation (D9310) and any type of oral evaluation be reported on the same date of
service?

A: No, D9310 includes an oral evaluation, and is part of the global service.

Q: How do we document and report interpretation services, as required by Section 1557 of the
Affordable Care Act (ACA)?

A: CDT code D9990 documents and reports interpretation services performed by a certified translator.

Section 1557 of the ACA prevents dental practices from charging a patient for interpretation services; however, document what you do. Case management efforts are sometimes required under federally funded programs as a way to quantify case management efforts, such as interpretation services.

Q: How is a blood glucose level test documented and reported?

A: Report D0412 blood glucose level test – in-office using a glucose meter. This reports either a fasting or
random glucose level. An Hba1c, which tests the average glucose level for the past 2-3 months, is reported with D0411.