CDT codes D4341, D4342, plus charging for topical local anesthesia

Question: I just started with a new office. In their treatment plan for periodontal scaling (D4341 and D4342) they also charge patients for topical local anesthesia. Is this now the standard?

Answer: You’re not alone with this question. It’s been asked repeatedly and seems to have become more frequent in recent years.

Let’s review what the ADA considers local anesthesia. Under Glossary of Dental Clinical Terms at ADA.org. the definition is: “Local anesthesia—the elimination of sensation, especially pain, in one part of the body by the topical application or regional injection of a drug.”

Beginning in CDT 4 (2003), the ADA Council on Dental Benefit Programs determined that, in general, the use of local anesthetics was considered a part of certain dental procedures and was not to be charged separately.

The following statement appears at the beginning of seven of the categories of service: “Local anesthesia is usually considered to be part of _____ procedures.” Those categories include restorative, endodontics, periodontics, removable prosthodontics, implant services, fixed prosthodontics, and oral and maxillofacial surgery.

So, why are there two local anesthesia codes included in the current CDT manual? It is unclear; however, these two CDT procedure codes do not differentiate whether the administration route is topically placed or injected (CDT 2024, p. 80):

• D9210 local anesthesia not in conjunction with operative or surgical procedures.
• D9215 local anesthesia in conjunction with operative or surgical procedures.

Topical anesthetic products are often used before injectable local anesthesia; however, dental hygienists also use these products to comfort sensitive patients during routine prophylactic procedures. Specific products designed to be used in place of injectable anesthesia exist and are most likely what you’re referring to in the question. The more prominent brands are Oraqix, Gingicaine, Cetacaine, and pharmacy-compounded gels that contain a mixture of topical anesthetics.

In 2016, the DentalCodeology Consortium submitted two code action request submissions to the ADA’s Code Maintenance Committee dealing with this topic. They were rejected as follows:

Adjunctive local anesthesia agents with the descriptor: Agents that can be used to improve patient comfort during and/or after dental procedures.

CMC’s rationale for rejection: “The CMC determined that this proposed addition is for techniques that are considered components of current CDT codes for local anesthesia (e.g., D9215 local anesthesia in conjunction with operative or surgical procedures).”

Transmucosal administration of local anesthetic agents with the descriptor: A noninjectable method of administration in which the local anesthetic drug is applied to and absorbed through mucous membranes. Examples include, but are not limited to, creams, gels, liquids, eutectic mixtures, aerosols, bio-adhesive-transdermal patches, and intranasal sprays.

CMC’s rationale for rejection: “The CMC determined that the procedure as described is an anesthetic delivery technique that is reportable with existing CDT code D9215 local anesthesia in conjunction with operative or surgical procedure. Techniques used in delivery of local anesthesia (e.g., injectable, topical) are not unbundled from the procedure as described in the current CDT code entry.”

It was clear that the CMC was adhering to the strict descriptor of the current local anesthesia procedure codes and did not want to unbundle any specific technique or delivery system. Since the question pertains to topical anesthesia for periodontal therapy, the correct procedure code would be D9210, as periodontal therapy is considered a nonsurgical procedure. Note that this would only be used to document and report the anesthesia and the product used and, in most cases, would not be a billable item.

If the office has chosen to enter a signed contract with a third-party insurance payer that specifically describes the use of local anesthesia as a “bundled” procedure, the use of separate billing for local anesthesia would not be permitted. The payer may even point to the language in the CDT manual that states that “local anesthesia is usually considered to be a part of the _____ procedure.”

Bundling is when distinct dental procedure codes are combined, and most of the time the result is a reduced benefit for the patient/beneficiary. Delta Dental recently published a letter to participating providers in April 2024 to address this issue. They stated, “We consider all locally administered anesthesia—whether via intramucosal injection, topical application, or other means—to be included in the fee for the procedure. Separate billing for anesthesia is not permissible.”

If the practice is a fee-for-service provider or the office is out-of-network with insurance companies, it would not fall under the same guidelines as defined above; however, charging a patient for a procedure that would already be considered an integral part of another procedure leaves most of us questioning its morality.

Offices often have not used the ADA CDT codes to document/report the use of local anesthesia but describe them thoroughly in the progress notes. There are also cases where a code is designated in the software for using a particular product or procedure, and there may or may not be a fee associated.

A word of caution: Use of local anesthetics in any form must be documented completely. Whether the practice decides not to include the procedure code or decides to include the proper CDT procedure code in their documentation to gather the metrics of how often these procedures are performed, the CDT manual clearly states that local anesthesia is a part of the procedure and, in general, should not be billed separately.