Contents:-

❖Introduction

❖ Dental Claims
❖ Anatomy & Types of Dentition.
❖ DHA Guidelines & Claiming Protocols
❖HAAD Guidelines & Claiming Protocols
❖Procedure Codes DUBAI (CDT).
❖Procedure Codes ABUDHABI (USC &
LS).
❖Abbreviation & Documentation
Elements.
❖Diagnosis Coding.
❖Coverage & Preauthorization.
 Introduction
DENTISTRY :- Dentistry is defined as the Evaluation, Diagnosis,
Prevention and/or Treatment
(nonsurgical, surgical or related procedures) of diseases, disorders and/or conditions of
the oral cavity, maxillofacial area and/or the adjacent and associated structures and their impact on
the human body; provided by a dentist, within the scope of his/her education, training and
experience, in accordance with the ethics of the profession and applicable law.

BRANCHES OF DENTISTRY:-

Orthodontics
Prosthodontics Oral Pathology

Paediatric dentistry Oral Medicine & Radiology.

Preventive dentistry & Community Dentistry.

Endodontics
Forensic Dentistry.

Periodontics
Oral and Maxillofacial Surgery
 Elements of Dental Claim
CLAIM ELEMENTS (Submitted to Payer)

✓ Diagnosis

✓ Procedure Codes (USCLS-

Canadian Dental codes)Al Ain (Audited by Payer)
Abu Dhabi and (CDT
American Dental Codes) • Clinical
Documentation &
✓ Tooth Number Observation Compliance.
Reporting

✓ Authorization Details
DOH and DHA Dental coding and
ADJUDICATION RULES

3. Codes Definitions:
Coding of healthcare products and services shall be in accordance
with:
❖ Dental Codes ( CDT) rules for DUBAI are established by ADA (
American Dental Association

❖Dental Codes (USC&LS) rules for Abu Dhabi are established by

the Canadian Dental Association, (Unified System of Codes and
List of Services)
Claiming Methodology
1. FEE FOR SERVICE

• TYPE OF ENCOUNTER :- Outpatient Dental treatment

1. Diagnostic Dental Treatment

2. Preventive & Restorative
3. Routine Periodontics
4. Prosthodontics (Fixed – Removable Dentures) etc.
5. Orthodontics (Braces, Appliances ) etc.
6. Paedodontics (SS crowns etc)
7. Oral Surgery ( Surgical Extractions)etc

2. PER DIEM

• TYPE OF ENCOUNTER :- Ambulatory /Day Care Dental treatment.

IP Dental Surgeries
 DENTAL ANESTHESIA
Preconditions.

Local anesthesia should be preferred whenever possible.

The benefits and risks of general anesthesia should be considered
before taking a decision.
Requirements :-
✓ A letter from the practitioner to the anesthetist with details of the
indication for general anesthesia and total time needed.
✓ Pre-Authorization.
✓ Pre-anesthesia consultation, providing information to patients /next
of kin.
Indications:

A. Member should be young with a dental condition that requires

repairs of significant complexity (e.g., multiple amalgam and/or
resin-based composite restorations, pulpal therapy, extractions, or
any combination of these or other dental procedures); or
 DENTAL ANESTHESIA
B. Member exhibits physical, intellectual, or medically-compromised conditions, for
which dental treatment under local anesthesia, with or without additional adjunctive
techniques and modalities, cannot be expected to provide; or

C. Member needs local anesthesia with dental treatment but the local anesthesia is/will
be ineffective because of acute infection, anatomic variation, or allergy; or

D. Member is extremely uncooperative, fearful, anxious, or uncommunicative with

dental needs of such magnitude or clinically apparent and functionally threatening to
the well-being of the individual that treatment should not be postponed or deferred,
and the lack of treatment can be expected to result in dental or oral pain, infection,
loss of teeth, or other increased oral or dental morbidity or mortality; or

E. Member has sustained oral-facial and/or dental trauma, for which treatment under
local anesthesia would be ineffective or compromised.
DENTAL ANESTHESIA
ANATOMY OF TOOTH
 TYPES OF DENTITION
PRIMARY DENTITION:- Normally, there are 20 primary teeth, 10 on each dental
arch:
. 4 incisors (2 central incisors and 2 lateral incisors), 2 canines and 4 molars.
 TYPES OF DENTITION
Permanent teeth

• Permanent teeth (or adult

teeth) are the second set of
teeth and normally consist of
32 teeth.

• The first permanent teeth

appear around the age of 6
and are usually the first molars
which erupt right behind the
last "milk" molars of the
primary dentition.

• The permanent premolars will

replace the milk molars of the
primary dentition and all
permanent molars will erupt
behind the deciduous teeth
UNIVERSAL TOOTH NUMBERING
PRIMARY DENTITION
UNIVERSAL TOOTH NUMBERING
PERMANENT DENTITION
SUPERNUMERARY TEETH , PERMANENT DENTITION
CDA Uniform System of Coding and
List of Services
CDA Uniform System of Coding and
List of Services
CDA Uniform System of Coding and
List of Services
CDA Uniform System of Coding and
List of Services
CDT CODES
 Components of a CDT Code
Procedure Code
Five character alphanumeric beginning with “D”

Nomenclature (name)
Written title of the procedure

D0210 ; intraoral - complete series of radiographic images

A radiographic survey of the whole mouth, usually consisting of 14-

22 periapical and posterior bitewing images

Descriptor (description)
Narrative providing further definition and intended use of the procedure; most but not
all codes have a descriptor ( Not always available)
 USCLS CODES (ABUDHABI)
The numbers used to describe a service must accurately conform to the following principles:
( 5 Digit codes.)

Categories of Services
• 01000-09999 Diagnosis
• 10000-19999 Prevention
• 20000-29999 Restoration
• 30000-39999 Endodontics
• 40000-49999 Periodontics
• 50000-59999 Prosthodontics - Removable
• 60000-69999 Prosthodontics - Fixed
• 70000-79999 Oral and Maxillofacial Surgery
• 80000-89999 Orthodontics
• 90000-99999 Adjunctive General Services
CDT CODES (DUBAI)
 USCLS CODES
The units of time and/or the letters following procedures must conform
to the following

• Where the: letter "L" follows a procedure code- "laboratory

procedures extra“

• Units of time follows a procedure code-"fifteen minute intervals“

• Letter "E" follows a procedure code-"expenses extra"

(not intended to cover expenses already factored into the fee for the procedure)
 ELEMENTS OF DENTAL
✓ CHIEF COMPLAINT DOCUMENTATION
✓ HISTORY OF PRSENTING ILLNESS

✓ PAST /PERTINENT MEDICAL HISTORY

✓ FAMILY & SOCIAL HISTORY

✓ CLINICAL EXAMINATION & CHARTING.

Intraoral Examination
Extra Oral Examination
HARD TISSUE EXAMINATION
SOFT TISSUE EXAMINATION

✓ Radiographic Findings.
✓ Charting

✓ Procedure note ( Detailed, instruments, techniques )

✓ Tooth number

✓ COUNSELLING , PATIENT EDUCATION

✓ & TREATMENT PLANNING

✓ FOLLOW-UP INSTRUCTIONS.
 DENTAL CHART-Most commonly used abbreviations
Arches:
Upper Arch = UA
Lower Arch = LA
Quadrants:
Upper Left = UL
Upper Right = UR
Lower Left = LL
Lower Right = LR

Prophylaxis done :- Scaling & Polishing.

OHI given :- “Oral Hygiene Instructions”

Infiltration :- Local area anesthesia.

NB :- Nerve Block

6M recall :- Follow-up after 6 months.

Edentulous:- ‘without teeth’

 Related Abbreviations :
Tooth Surfaces:

Anterior tooth Posterior Tooth

Facial/Labial = F Buccal = B
Incisal = I Occlusal = O
Mesial = M Mesial = M
Lingual = L Lingual = L
Distal = D Distal = D
Example of tooth charting
DIAGNOSIS :- DENTAL CARIES
 RADIOGRAPHS
BITEWING
OCCLUSAL -INTRAORAL cephalometric x ray

PERI-APICAL
OPG- ORTHOPANTAMOGRAPH
CBCT
DENTAL ICD10 CODES
 DISEASES &
DISORDERS OF THE
ORAL CAVITY &
MAXILLOFACIAL AREA
& ADJACENT
STRUCTURES
K SERIES
 DISEASES & DISORDERS OF THE ORAL CAVITY &
MAXILLOFACIAL AREA & ADJACENT STRUCTURES
K SERIES
K00.0 Anodontia K04.7 Periapical abscess without sinus
K00.1 Supernumerary teeth
K00.2 Abnormalities of size and form of teeth
K04.5
K00.3 Mottled teeth Chronic apical periodontitis
K00.4 Disturbances in tooth formation K04.6 Periapical abscess with sinus
K00.5 Hereditary disturbances in tooth structure, not elsewhere classified
K00.6 Disturbances in tooth eruption K04.8 Radicular cyst
K00.7 Teething syndrome K04.90 Unspecified diseases of pulp and periapical tissues
K00.8 Other disorders of tooth development
K00.9 Disorder of tooth development, unspecified K04.99 Other diseases of pulp and periapical tissues
K01.0 Embedded teeth K05.00 Acute gingivitis, plaque induced
K01.1 Impacted teeth
K02.9 Dental caries, unspecified K05.01 Acute gingivitis, non-plaque induced
K02.51 Dental caries on pit and fissure surface limited to enamel K05.10 Chronic gingivitis, plaque induced
K02.61 Dental caries on smooth surface limited to enamel
K02.52 Dental caries on pit and fissure surface penetrating into dentin K05.11 Chronic gingivitis, non-plaque induced
K02.62 Dental caries on smooth surface penetrating into dentin K06.0 Gingival recession
K02.53 Dental caries on pit and fissure surface penetrating into pulp
K02.63 Dental caries on smooth surface penetrating into pulp K06.1 Gingival enlargement
K02.3 Arrested dental caries K06.2 Gingival and edentulous alveolar ridge lesions associated with trauma
K03.89 Other specified diseases of hard tissues of teeth
K02.7 Dental root caries K06.9 Disorder of gingiva and edentulous alveolar ridge, unspecified
K03.0 Excessive attrition of teeth K05.20 Aggressive periodontitis, unspecified
K03.1 Abrasion of teeth
K03.2 Erosion of teeth K05.21 Aggressive periodontitis, localized
K03.3 Pathological resorption of teeth K05.22 Aggressive periodontitis, generalized
K03.4 Hypercementosis
K03.5 Ankylosis of teeth K05.30 Chronic periodontitis, unspecified
K03.7 Posteruptive color changes of dental hard tissues K05.31 Chronic periodontitis, localized
K03.81 Cracked tooth
K03.9 Disease of hard tissues of teeth, unspecified K05.32 Chronic periodontitis, generalized
K04.0 Pulpitis K05.4 Periodontosis
K04.1 Necrosis of pulp
K04.2 Pulp degeneration K03.6 Deposits [accretions] on teeth
K04.3 Abnormal hard tissue formation in pulp K05.5 Other periodontal diseases
K04.4 Acute apical periodontitis of pulpal origin
K05.6 Periodontal disease, unspecified
 DISEASES & DISORDERS OF THE ORAL CAVITY &
MAXILLOFACIAL AREA & ADJACENT STRUCTURES
M Series
M26.00 Unspecified anomaly of jaw size
M26.219 Malocclusion, Angle's class, unspecified
M26.01 Maxillary hyperplasia
M26.03 Mandibular hyperplasia
M26.50 Dentofacial functional abnormalities, unspecified
M26.02 Maxillary hypoplasia M26.51 Abnormal jaw closure
M26.04 Mandibular hypoplasia M26.52 Limited mandibular range of motion
M26.05 Macrogenia
M26.06
M26.53 Deviation in opening and closing of the mandible
Microgenia
M26.07 Excessive tuberosity of jaw M26.54 Insufficient anterior guidance
M26.09 Other specified anomalies of jaw size M26.55 Centric occlusion maximum intercuspation discrepancy
M26.10 Unspecified anomaly of jaw-cranial base relationship
M26.11 Maxillary asymmetry M26.56 Non-working side interference
M26.12 Other jaw asymmetry M26.57 Lack of posterior occlusal support
M26.19 Other specified anomalies of jaw-cranial base relationship M26.59 Other dentofacial functional abnormalities
M26.20 Unspecified anomaly of dental arch relationship
M26.211
M26.60 Temporomandibular joint disorder, unspecified
Malocclusion, Angle's class I
M26.212 Malocclusion, Angle's class II M26.61 Adhesions and ankylosis of temporomandibular joint
M26.213 Malocclusion, Angle's class III M26.62 Arthralgia of temporomandibular joint
M26.220 Open anterior occlusal relationship
M26.221 Open posterior occlusal relationship
M26.63 Articular disc disorder of temporomandibular joint
M26.23 Excessive horizontal overlap M26.69 Other specified disorders of temporomandibular joint
M26.24
Reverse articulation M26.70 Unspecified alveolar anomaly
M26.25 Anomalies of interarch distance
M26.71 Alveolar maxillary hyperplasia
M26.29 Other anomalies of dental arch relationship
M26.30 Unspecified anomaly of tooth position of fully erupted tooth or teeth
M26.72 Alveolar mandibular hyperplasia
M26.31 Crowding of fully erupted teeth M26.73 Alveolar maxillary hypoplasia
M26.32 Excessive spacing of fully erupted teeth M26.74 Alveolar mandibular hypoplasia
M26.33 Horizontal displacement of fully erupted tooth or teeth
M26.34 M26.79 Other specified alveolar anomalies
Vertical displacement of fully erupted tooth or teeth
M26.35 Rotation of fully erupted tooth or teeth M26.81 Anterior soft tissue impingement
M26.36 Insufficient interocclusal distance of fully erupted teeth (ridge) M26.82 Posterior soft tissue impingement
M26.37 Excessive interocclusal distance of fully erupted teeth
M26.39
M26.89 Other dentofacial anomalies
Other anomalies of tooth position of fully erupted tooth or teeth
M26.4 Malocclusion, unspecified M26.9 Dentofacial anomaly, unspecified
S00.511A Abrasion of lip, initial encounter
S00.511D Abrasion of lip, subsequent encounter
S00.511S Abrasion of lip, sequela
DISEASES & DISORDERS OF
S00.512A

S00.512D
Abrasion of oral cavity, initial encounter THE ORAL CAVITY &
Abrasion of oral cavity, subsequent encounter
S00.512S Abrasion of oral cavity, sequela MAXILLOFACIAL AREA &
S00.521A

S00.521D
Blister (nonthermal) of lip, initial encounter

Blister (nonthermal) of lip, subsequent encounter

ADJACENT STRUCTURES
S00.521S Blister (nonthermal) of lip, sequela S Series
S00.522A Blister (nonthermal) of oral cavity, initial encounter
S00.522D Blister (nonthermal) of oral cavity, subsequent encounter
S00.522S Blister (nonthermal) of oral cavity, sequela
S00.531A Contusion of lip, initial encounter
S00.531D Contusion of lip, subsequent encounter
S00.531S Contusion of lip, sequela
S00.532A Contusion of oral cavity, initial encounter
S00.532D Contusion of oral cavity, subsequent encounter
S00.532S Contusion of oral cavity, sequela
S02.5XXA Fracture of tooth (traumatic), initial encounter for closed fracture
S02.5XXB Fracture of tooth (traumatic), initial encounter for open fracture

S02.5XXD
Fracture of tooth (traumatic), subsequent encounter for fracture with routine healing

S02.5XXG
Fracture of tooth (traumatic), subsequent encounter for fracture with delayed healing
S02.5XXK Fracture of tooth (traumatic), subsequent encounter for fracture with nonunion
S02.5XXS Fracture of tooth (traumatic), sequela
S03.2XXA Dislocation of tooth, initial encounter
S03.2XXD Dislocation of tooth, subsequent encounter
 OTHER DENTAL CODES
Z series ( Screening / Follow-up)

Z48.02 Suture removal

Z46.3 Encounter for fitting and adjustment of dental prosthetic device
Z46.4 Encounter for fitting and adjustment of orthodontic device

Don’t use Dental restoration status code Z98.811 with K08.530/K08.531

Don’t use Z01.21 alone (Use additional code for abnormal findings)
Use Z01.20 If patient came for checkup and no abnormal findings
 Dental Fractures Dx codes
 Fractured Restoration
K08.530 Fractured dental restorative material without loss of material
K08.531 Fractured dental restorative material with loss of material

 Fractured Tooth
K08.539 Fractured dental restorative material, unspecified

S02.5XXA Fracture of tooth (traumatic), initial encounter for closed fracture

S03.2XXA Dislocation of tooth, initial encounter

Don’t forget to add external cause of injury code

W18.30XA Fall on same level, unspecified, initial encounter

❖ Cracked tooth
K03.81 Cracked tooth
Note: Don’t use K08.531 and K08.50 together
Don’t use K03.81 and K08.53… for the same tooth
EVALUATION CODES
 Prevention :- 10000-19999 ( ABUDHABI)

Dental plaque is a biofilm or mass of bacteria that grows on surfaces within the mouth.
Causing Gingivitis.

Calculus is a form of hardened dental plaque & it’s a Chronic condition- causing
Periodontitis

iagnosis Code K03.6, K05.10, K05.00

Only allowed twice a year
 Restoration :- 20000-29999 K02 DENTAL CARIES
DENTAL CARIES
 Restoration
 RESTORATION Dubai Standards of Care (2018)- Dental Billing Rules;

 When multiple restorations for the same tooth are requested or performed, multi-
surface codes should be used. It’s not accepted to bill each surface separately
 Example: if a composite filling is done in buccal and occlusal surfaces. The provider
should use the code: resin-based composite - two surfaces, posterior.
 All restorations (direct or indirect), should include: Tooth preparation, adhesives,
etching, liners, bases, pulp capping, temporary restorations, buildups, cement,
impressions, laboratory fees, filling material, polishing, occlusal adjustment, re-cement
and local anesthesia
 Restoration provided for cosmetic purposes are non-payable
 The QUANTITY of fillings is limited to four fillings per claim/per day (not applied for
general anesthesia cases).
 TREATMENT :-RESTORATIVE (Dubai)

MATERIAL USED :-

✓ SILVER AMALGAM

✓ GLASS IONOMER
CEMENT

✓ COMPOSITES etc
TREATMENT :-RESTORATIVE (Dubai)
 TREATMENT :-RESTORATIVE (AbuDhabi)

MATERIAL USED :-

✓ SILVER AMALGAM

✓ GLASS IONOMER
CEMENT

✓ COMPOSITES etc
 DUBAI
Root Canal treatment – or Pulpectomy

Diagnosis Code K04.7

Synonyms:-
Dental abscess
Dental infection
Infection of tooth
Peri apical abscess
Peri apical abscess without sinus tract
 DUBAI
Root Canal treatment – or Pulpectomy

Diagnosis Code K04.7

Synonyms:-
Dental abscess
Dental infection
Infection of tooth
Peri apical abscess
Peri apical abscess without sinus tract
Endodontic :- 30000-39999 (DUBAI)
 Endodontic :- 30000-39999 (ABUDHABI)
Root Canal treatment – or Pulpectomy

Diagnosis Code K04.7

Synonyms:-
Dental abscess
Dental infection
Infection of tooth
Peri apical abscess
Peri apical abscess without sinus tract
DUBAI
DUBAI
Periodontics:- 40000-49999 (ABUDHBAI)
DUBAI
 DUBAI

Crown & Bridge

All Ceramic crowns.

DUBAI
 Prosthodontics Removable :- 50000-
59999

Exclude 1 (K08.1** and K08.4**..)

Prosthodontic Codes
 Prosthodontics Fixed :- 60000-69999

Crown & Bridge

All Ceramic crowns.

Coverage
 Dental benefit Coverage :-
✓ Basic Product members:
Dental services are not covered for the Basic Product members, except in case of
emergency.

TABLE OF BENEFITS INTERPRETATION

✓ Optional Benefit:-
✓ Reimbursement Basis:- “Pay & Claim” basis.
✓ Waiting period :
✓ Co-insurance:-
✓ Sublimit:-
✓ Out of Net work “No Coverage”:-
✓ Preventive & Cosmetic Dental Treatments:- (Policy exclusion)
✓ Implants are not covered
✓ Crowns are not a part of ROUTINE DENTAL TREATMENT.
Coverage – Facts (DUBAI)
▪ Orthodontic Treatment:-
Coverage for this codes is limited to members who have Orthodontic Plan Benefits.
▪ Major Dental Surgery
-The following surgical services include necessary local anesthetic, removal of excess gingival
tissue, suturing and one postoperative treatment, when required.

▪ DENTAL RADIOGRAPHS
Coverage – Facts ( ABUDHABI)
▪ Orthodontic Treatment:-
It cannot be covered for more than once per case per provider.
Subject to Pre-authorization –for Direct Billing /Reimbursement
It cannot be billed in the same invoice/billing month, as the “monthly follow-up” sessions- 93332.

▪ Major Dental Surgery

-The following surgical services include necessary local anesthetic, removal of excess gingival
tissue, suturing and one postoperative treatment, when required.

▪ Dental radiographs are not covered for Insured without the optional dental benefit
✓ Panoramic X-Ray (02601) is limited to one per examination per year per policy, unless
otherwise indicated. e.g. Post-op radiograph after implant placement.
✓ Occlusal X-Ray (02131) is covered only for: Canine Impactions, Oral Tumors & Salivary
Stones.
✓ Bitewing X-Ray (02141) is covered in cases of dental caries for posterior teeth (provided
the tooth number is mentioned), to detect pocket depths more than 3 mms and to
detect open restoration margins. Max of 2 can be paid for an examination.
✓ Per apical X-Ray (02111) is limited to a max of 2/Restoration, 4/RCT and 8/Full mouth Examination
✓ Tomography is covered for Implant cases in case of Loss of Teeth and Partial/Complete Edentulism.
It can also be used in deep impaction cases related to vital structures, cysts or tumors.
Prosthodontic and Orthodontic
Approvals (ABUDHABI)
 OPG
 PA
 Digital Photos
 Assessment form ( For Orthodontic approvals)
 Justification /medical reports if required
Claims related Questions
 DENTAL DENIALS
 1. Denial code Clai016, Code013
CODE-013 Invalid principal diagnosis (for example E-codes)

CLAI-016 Incorrect billing regime

Unspecified
Examples for CLAI-016 codes

M26.211,M26.09,M26.35,M26.24,M26.219,M26.33,M26.25 M26.09 Other specified anomalies of jaw size

Disease of hard tissues of teeth,

Z01.21,K02.62,K03.6,K03.9,K05.00 K03.9 unspecified

M26.213,M26.03,M26.29,M26.24,M26.00,M26.33,M26.31 M26.00 Unspecified anomaly of jaw size

Other denial: MNEC003- MNEC-004, MNEC-005, NCOV-001, PRCE-002, Eleg-001,

 Dental Codes with Unit of Time
 Scaling and Polishing
Add time for each unit in documentation.
UCSLS 11101 POLISHING One unit of time

UCSLS 11109 POLISHING Each additional unit over two

UCSLS 11111 SCALING One unit of time

UCSLS 11119 SCALING Each additional unit over six

UCSLS 11101 POLISHING One unit of time

UCSLS 11102 POLISHING Each additional unit over two For CASH patient

UCSLS 11111 SCALING One unit of time

UCSLS 11119 SCALING Each additional unit over six

Prosthodontic and Orthodontic
Approvals (ABUDHABI)
 OPG
 PA
 Digital Photos
 Assessment form ( For Orthodontic approvals)
 Justification /medical reports if required
DENTAL AUDITS AND
DOCUMENTATION
 1. Some important Points
1. Time based code time is each unit must be minimum 10min
2. Restoration procedure notes always write correct number of surface
and name of surfaces
3. Orthodontic monthly visit billing minimum 21 days
4. Tooth charting when billing full mouth examination
5. Narrative diagnosis in intraoral examination
6. Complete procedure note
7. Complete documentation within 24hours
8. Audit logs