Insurance Codes Vs. Procedure Codes: What’s the Difference?

Kathy Forbes


“Where can I find the Insurance Codes book?” asks Sandy, the recently hired billing employee. The receptionist replies “I don’t know!” as she is attempting to answer the phone and check out a patient at the same time. The dental assistant, escorting a patient to the clinic area, barks back “How would I know?”

As Sandy searches around the front desk area, opening cupboards and scanning bookshelves, she sees numerous financial report notebooks, MSDS folders, HIPAA manuals, and more but nothing with the title Insurance Codes. As she frantically keeps searching, the office manager asks if she can help.

Sandy explains she is following up on a claim and has an insurance rep on the phone. The insurance company has declined to pay for a D4910 “due to frequency limitations” and told her to resubmit with “insurance code D1110.” Since she is new to dentistry, she wanted to look up the code before resubmitting the claim. “Where is the Insurance Codes book?” she asks again.

The Real World

Sound familiar? Well, the answer is that there is no Insurance Codes book. Many dental staff mistakenly refer to the procedure codes in the ADA’s CDT 2021: Current Dental Terminology as insurance codes. Why? The primary reason is when staff members select a procedure code, they are usually thinking about how an insurance carrier may be reimbursing the code. And if one code has limited or no benefits, what other code could be submitted to receive reimbursement?

Consider insurance carriers who ask your office to remap the submitted procedure code to a different code, even if it is not the procedure you provided, to get some type of reimbursement. Should you use creative billing? What do you do?

According to the ADA Principles of Ethics and Code of Conduct, “A dentist who incorrectly describes on a third-party claim form a dental procedure in order to receive a greater payment or reimbursement… is engaged in making an unethical, false or misleading representation to such third party.”

In fact, many dental and dental hygiene practice acts have this language included in their statutes and rules, and failing to adhere to this guideline could be grounds for disciplinary action.

The ADA’s CDT 2021 Coding Companion describes the “Golden Rules” of procedure coding, which include:

• Code for what you do.

• After reading the full nomenclature and descriptor, select the code that matches the procedure delivered to the patient

• Treatment planning is based on clinical need, not covered services.

Submitting correct procedure codes to insurance carriers also allows them and others to assemble data, also known as metrics, to develop evidence-based guidelines for clinical care as well as determine if additional procedure codes need to be developed to accurately reflect current treatment modalities.

Patient Education & Big Data

It’s important to educate patients about their dental insurance, especially related to plan exclusions so that there are no surprises. Coding expert Teresa Duncan advises, “Try to keep a tone of understanding, but remember, this is their plan and its design is not your fault! Use phrases like, ‘I’ve run into this clause before and it’s unfortunate. Let’s figure out how we can make the payments work for you.’”

Coding expert Patti DiGangi notes that dentistry is becoming a more diagnosis-based profession. Therefore, accurate procedure code selection and submission must be followed. Patients must be informed of what dental insurance is and is not.

“It is the responsibility of the practice/practitioner to use the most accurate codes describing the care rendered. And using the most accurate code adds to our body of big data with the appropriate metric,” DiGangi says.

Dental hygienists are in a powerful position to add to the big data by virtue of the many procedures which they can and are performing on a regular basis.

“The existence of a code does not mean that the procedure is a covered or reimbursed benefit in a dental benefit plan,” according to the CDT 2021 Coding Companion.

The sad truth is that most hygienists don’t even list the valuable treatment procedures they provide. They ask why they should list these procedures since the insurance company won’t pay for them. But how will the insurance companies know hygienists are providing these services if the hygienists don’t tell them?

A classic example of this came at an ADA Code Maintenance Committee meeting several years ago when an insurance carrier submitted for a code for Gingival Irrigation-per quadrant because it was receiving so many claims with it listed as an unspecified procedure. By having a separate code, companies are now better able to track how often the procedure was being provided.

Hygienists can also use the data to demonstrate their value to the practice even if the procedure code doesn’t have a fee. After all, the hygienists’ value is not just based on the dollars they produce!

There are the intangibles, such as getting along well with patients and helping promote restorative options. But having the metrics from the monthly reports can help bolster just how much hygienists are contributing outside of the “cleaning” procedures.

Know Your Codes

Each state dental and dental hygiene practice act outlines procedures that dental hygienists can and cannot perform. But consider the following partial listing of codes and procedures that are being performed but not necessarily documented in the chart or submitted on the claim form:

• D0191: Assessment of a patient
• D0350: 2D oral/facial photographic image obtained intraorally or extraorally
• Many codes: Tests and examinations for salivary collection, preparation, etc.
• D1310: Nutritional counseling for control of dental disease
• D1320: Tobacco counseling for the control and prevention of oral disease
• D1330: Oral hygiene instructions [should be included on all patients]
• D1353: Sealant repair
• D4921: Gingival irrigation—per quadrant
• D5986: Fluoride gel carrier
• D9311: Consultation with a medical healthcare professional
• D9430: Office visit for observation (during regularly scheduled hours)
• D9630: Drugs or medicaments dispensed in the office for home use
• D9910: Application of desensitizing medicament
• D9932: Cleaning and inspection of removable complete denture, maxillary
• D9933: Cleaning and inspection of removable complete denture, mandibular
• D9934: Cleaning and inspection of removable partial denture, maxillary
• D9935: Cleaning and inspection of removable partial denture, mandibular
• D9975: External bleaching for home application, per arch

In CDT 2021: Current Dental Terminology, the ADA provides all dental practices with a CDT Manual outlining:

• The Procedure Code, which is a five-character number
• The Nomenclature, which is the written title
• The Descriptor, which is a written narrative.

The manual is updated yearly and available in October, prior to the January 1 start date. It is imperative that all clinical staff members be aware of any additions, deletions, or amendments to any of the procedures they provide. It is not solely the administrative staff’s responsibility!

In October, assign sections to appropriate staff members, including the dentists. Then have a staff meeting in the beginning of December for everyone to share changes and how the practice will handle discussions with patients. This is a whole office effort!

Remember, these are not insurance codes! As in medicine, procedure codes describe the treatment for the diagnosis and provided by healthcare providers in accordance with their state dental and dental hygiene practice acts.


A special thank you to Patti DiGangi, RDH, BS, DentalCodeologist, and Teresa Duncan, MS, FADIA, FAADOM, of Odyssey Management, for sharing their expertise related to CDT Procedure Codes during the writing of this article. It truly takes a network of key opinion leaders to keep on track with dental procedure coding to better serve our practices and our patients.

Ms. Forbes holds a CDT coding license with the American Dental Association as well as being a Director for the DentalCodeology™ Consortium, founded by Patti DiGangi, RDH, BS. She is the president of Professional Dental Seminars and has been a dental hygienist, educator, speaker, author, and seminar and study club leader for more than 40 years. Her national engagements include presentations at the ADA Annual meeting; ADHA Center for Lifelong Learning, RDH Under One Roof, the Pacific Northwest Dental Conference and Beyond Oral Health. She has articles published in RDH Magazine and the Insurance Solutions Newsletter specifically addressing dental hygiene treatment planning and correct procedure code selection. Kathy recently moved to Fort Worth, TX after having a long career in Dental Hygiene Education both in Washington state and Colorado. She can be reached at