Many dental patients often show signs of clenching and grinding during sleep or even during normal daytime activities. With the day-to-day stress people experience, dentists are seeing a rising need to provide appliances to treat grinding, clenching and to prevent cracked teeth. As providers, you need to know: What is the new code for a hard nite guard? Does medical insurance pay for occlusal guards? Why was my claim for D9940 denied?

This article will focus on custom hard and soft occlusal guards and how to properly document and report these procedures to dental payers. When we refer to a custom appliance, we are referring to an appliance that is custom fabricated for a specific patient. A series of data is taken to include models whether these models are traditional impressions poured with stone or taken digitally using scanner technology. The custom appliance is fabricated outside of the mouth using these models and any other data gathered.

The CDT code, D9940 was deleted from the CDT code set in 2019. D9940 was a “by report” code and was broadly defined by the nomenclature, preventing dentists from accurately documenting the procedure rendered. Three codes replaced D9940 to allow for greater specificity in describing the procedure. The three current codes accurately describe the material used and whether the appliance covers a full arch or a partial arch.

What’s the purpose of an occlusal guard?

One common condition is bruxism. A non-invasive treatment available for bruxism and other occlusal-related conditions is an oral appliance referred to as an occlusal guard or “nite guard.”

An occlusal guard protects the teeth from an occlusal factor such as bruxism. Wearing an occlusal guard can prevent further damage such as wear or fracturing of natural teeth or crown and bridge restorations that could occur as a result of clenching and grinding. In addition, an occlusal guard aids in reducing the uncomfortable, sometimes painful symptoms of bruxism.

Hard or soft appliance, what’s the difference?

The condition being treated determines whether the appliance is fabricated from a soft or hard acrylic material. Some patients may only clench or only grind their teeth while others may do both! The patient’s condition being treated may be minimal or mild to severe. The severity of the condition often dictates the type of appliance therapy required.

• A soft appliance is pliable whereas a hard appliance is rigid. A soft appliance flexes in the mouth while a hard appliance does not.
• A hard appliance may be fabricated with an added soft liner. The soft liner provides comfort for the patient and plays no role in the therapeutic effects of treatment. Therefore this type of appliance is considered a hard occlusal guard.
• An occlusal guard may cover the entire arch or a partial arch.
• A hard appliance covering a partial arch may be referred to as an NTI type appliance or an anterior deprogrammer. An occlusal appliance is not used to treat TMD but rather occlusal factors that may contribute to the symptoms.
• Appliances to treat TMD are not occlusal guards and are appropriately documented and reported using CDT code D7880.
• Occlusal guard codes are not to be used to document and report a sleep or snoring appliance.

As we have learned, choose the code based on whether it is a soft or hard appliance and whether it covers a full or partial arch. The current CDT codes to be used to document occlusal guards are as follows.

D9944 occlusal guard – hard appliance, full arch
A removable dental appliance designed to minimize the effects of bruxism or other occlusal factors. Not to be reported for any type of sleep apnea, snoring, or TMD appliances.

D9945 occlusal guard – soft appliance, full arch
A removable dental appliance designed to minimize the effects of bruxism or other occlusal factors. Not to be reported for any type of sleep apnea, snoring, or TMD appliances.

D9946 occlusal guard – hard appliance, partial arch
A removable dental appliance designed to minimize the effects of bruxism or other occlusal factors. Provides only partial occlusal coverage such as anterior deprogrammer. Not to be reported for any type of sleep apnea, snoring, or TMD appliances.

Clinical documentation of CDT codes regarding occlusal appliances

It is crucial that your clinical documentation fully supports the medical necessity of an occlusal guard. Always document the condition you are treating with specificity. For example, if the diagnosis is bruxism, does it occur during sleep or non-sleep related? Are you treating excessive attrition? Be specific in your documentation as to the “why” in addition to the description of the appliance, including whether it is a soft or hard appliance and if it is a full or partial arch coverage.

Dental plan reimbursement of occlusal appliances

Many dental plans exclude coverage for occlusal guards, regardless of the reason. Some dental plans, however, will allow coverage for a diagnosis of bruxism only. While others will allow coverage only for what is known as a “perio guard” placed within 6 months following osseous surgery. Always include a narrative with the diagnosis; why an occlusal guard is required, what condition is being treated. It is advisable to verify coverage prior to initiating treatment.

Does medical insurance pay for occlusal guards?

Possibly. Coverage under a patient’s medical plan for occlusal guards varies greatly. However, there may be coverage when the patient’s condition being treated meets the medical necessity requirements of the patient’s plan. Contact the medical payer to determine coverage for occlusal guards under the patient’s plan. When verifying coverage be sure to have the appropriate procedure code and ICD-10-CM diagnosis code(s) available.

When it comes to nite guards and any other occlusal appliance, keeping your knowledge up-to-date ensures your practice gets reimbursed correctly. As you can see, knowing how to determine the appropriate code and documentation is complicated! The training webinar Oral Appliances and Beyond scheduled for late 2021 has more details. So see your dental claims get paid faster. Learn about training programs (and CE credit) at Dental Claims Academy.

Specificity in documentation is key. Only the specific diagnoses documented in the clinical note may be reported. A medical plan may require prior approval when coverage is available for occlusal guards under the patient’s medical plan.

Current Dental Terminology, © 2020 American Dental Association. All rights reserved.

About the Author:
Dilaine Gloege is a dental billing author, educator, speaker, and consultant with more than 35 years of dental and insurance claims experience.
She helps dental practice owners succeed through profitable, legitimate insurance claims reimbursement. She speaks, presents, and consults on dental and medical billing nationwide. Dilaine has consulted with staff in thousands of dental practices in her role with Dr. Charles Blair’s Insurance Solutions Newsletter and PracticeBooster. As Director of Education for Dental Claims Academy, she leads programs to help practice owners develop a team of in-house billing experts. Dilaine is the author of a forthcoming book on coordination of benefits. Find her dental coding education articles in the Learning Center at Dental ClaimSupport.