When is D0474 used?
The D0474 dental code applies to the complete processing of tissue specimens, including both visual and microscopic analysis, with specific evaluation of surgical margins for disease detection, sample preparation, and delivery of a comprehensive written report. This code is typically utilized when dental professionals send tissue samples—such as biopsies from oral abnormalities or concerning growths—for pathological review. D0474 is suitable when comprehensive gross (physical and visual) and microscopic (histological) examinations are conducted, and when the final report specifically evaluates whether disease is present at the surgical margins.
Remember to apply D0474 only when all aspects of the code requirements are satisfied. If solely a visual examination occurs without microscopic study, or if margin evaluation is not included in the report, an alternative CDT code might be more suitable. Always confirm the clinical situation and records before selecting D0474 to prevent claim rejections or processing delays.
D0474 Charting and Clinical Use
Proper documentation is essential for successful D0474 billing. The patient record must clearly document:
The indication for tissue sampling (e.g., abnormal lesion, chronic ulceration, or mass).
Specifics of the surgical intervention, including location and technique of tissue collection.
Verification that complete gross and microscopic evaluations were conducted.
Evaluation of surgical boundaries for disease detection or clearance.
Creation and delivery of a comprehensive pathology report to the referring dental provider or oral surgeon.
Typical clinical applications include tissue sampling of oral soft tissue abnormalities, removal of benign or malignant tissues, and analysis of specimens obtained during gum surgery. If the procedure involves only cellular sampling or alternative tissue evaluation methods, determine if another code, such as D0470 (diagnostic casts), would be more appropriate.
Billing and Insurance Considerations
To maximize reimbursement and reduce claim denials for D0474, implement these strategies:
Prior approval: Certain insurance plans mandate pre-approval for pathological services. Check coverage details and secure authorization before treatment when required.
Comprehensive claim documentation: Include the pathology report and clinical documentation with the claim. Clearly demonstrate the medical necessity of the examination and margin evaluation.
Accurate code selection: Verify that D0474 properly represents the services provided. Inappropriate coding may result in EOB rejections or documentation requests.
Claim review process: When claims are rejected, examine the EOB for specific reasons. File an appeal with comprehensive supporting materials, including pathology findings and clinical justification.
AR monitoring: Maintain oversight of accounts receivable to ensure prompt follow-up on outstanding or underpaid D0474 claims.
How dental practices use D0474
Clinical Example: A 62-year-old patient arrives with a chronic white lesion on the side of the tongue. The dental provider performs surgical removal of the abnormal tissue and forwards the specimen for pathological analysis. The laboratory performs comprehensive visual and microscopic evaluation, examining the surgical boundaries for signs of abnormal cell changes or cancer. A thorough written report is generated and forwarded to the dentist, indicating clear surgical margins with no malignant findings. In this situation, D0474 represents the correct billing code for the pathology service, since all components of the code requirements have been met.
Through proper understanding of the appropriate use, documentation requirements, and billing procedures for D0474, dental offices can ensure proper reimbursement while supporting excellent patient treatment.
Common Questions
Can D0474 be submitted with other biopsy or pathology procedure codes?
D0474 cannot be billed together with other biopsy or pathology codes when they relate to the same specimen or procedure. When multiple specimens are involved, each requires separate documentation, and only the correct code for each examination type should be applied. Always review payer policies to prevent duplicate billing or bundling conflicts.
Which party bills D0474—the dental office or the pathology laboratory?
Generally, the pathology laboratory conducting the gross and microscopic analysis and generating the written report handles billing for D0474. In certain situations, the dental provider may submit the billing if they directly participate in both specimen collection and pathological evaluation. Proper coordination between the provider and laboratory is crucial to avoid duplicate billing practices.
What out-of-pocket expenses might patients face for D0474?
Patient financial responsibility for D0474 varies based on their individual dental or medical insurance coverage. Certain plans may impose deductibles, copayments, or coinsurance on pathology services, while others may exclude coverage entirely. Benefits verification and patient notification of potential costs should occur prior to performing the procedure.