Understanding Dental Code D0474

When to Use D0474 dental code

The D0474 dental code is designated for the accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation, and transmission of a written report. This code is most commonly used when a dental provider submits tissue specimens—such as biopsies from oral lesions or suspicious growths—for pathological evaluation. D0474 is appropriate when both gross (visual and manual) and microscopic (histopathological) examinations are performed, and when the report specifically addresses the presence or absence of disease at the surgical margins.

It is important to use D0474 only when the full scope of the code description is met. If only a gross examination is performed without microscopic analysis, or if the report does not include margin assessment, a different CDT code may be more appropriate. Always verify the clinical scenario and documentation before assigning D0474 to avoid claim denials or delays.

Documentation and Clinical Scenarios

Accurate documentation is critical for successful billing of D0474. The clinical record should clearly state:

• The reason for the tissue removal (e.g., suspicious lesion, persistent ulcer, or mass).
• Details of the surgical procedure, including the site and method of tissue removal.
• Confirmation that both gross and microscopic examinations were performed.
• Assessment of surgical margins for disease presence or absence.
• Preparation and transmission of a written pathology report to the referring dentist or oral surgeon.

Common clinical scenarios include biopsies of oral mucosal lesions, excision of benign or malignant growths, and evaluation of tissue removed during periodontal surgery. If the case involves only a cytological smear or a different type of tissue analysis, consider whether another code, such as D0470 (diagnostic casts), may be more suitable.

Insurance Billing Tips

To optimize reimbursement and minimize claim rejections for D0474, follow these best practices:

• Pre-authorization: Some dental plans require pre-authorization for pathology services. Verify benefits and obtain approval before the procedure when possible.
• Detailed claim submission: Attach the pathology report and clinical notes to the claim. Clearly indicate the necessity of the examination and margin assessment.
• Use correct CDT code: Double-check that D0474 accurately reflects the services rendered. Incorrect coding can lead to EOB denials or requests for additional information.
• Appeals process: If a claim is denied, review the EOB for the reason. Submit a claim appeal with supporting documentation, including the pathology report and clinical rationale for the examination.
• Track AR: Monitor accounts receivable to ensure timely follow-up on unpaid or underpaid claims involving D0474.

Example Case for D0474

Case Study: A 62-year-old patient presents with a persistent white patch on the lateral border of the tongue. The dentist performs a surgical excision of the lesion and submits the tissue for pathological evaluation. The pathology lab conducts both gross and microscopic examinations, assessing the surgical margins for evidence of dysplasia or malignancy. A detailed written report is prepared and sent to the dentist, confirming clear margins and no malignancy. In this scenario, D0474 is the appropriate code to use for billing the pathology service, as all elements of the code description are fulfilled.

By understanding the correct application, documentation, and billing process for D0474, dental practices can ensure accurate reimbursement and support optimal patient care.