National Committee on Vital and Health Statistics (NCVHS)

Subcommittee on Standards and Security

Testimony of:

The American Dental Association

January 28, 2004

Prepared and submitted by:

Albert H. Guay, D.M.D.

Chief Policy Advisor

American Dental Association

211 East Chicago Avenue

Chicago:City, IL 60611

312-440-2844 (voice)

312-440-2520 (fax)

Dr. Cohn, members of the Subcommittee and my colleagues in the health care community.  Good morning.  My name is Al Guay and I am the Chief Policy Advisor at the American Dental Association.  On behalf of the Association I would like to express our appreciation of the NCVHS interest in dental standards and code sets.  Today I have basically two items of business to discuss.  First, I would like to provide you with an update on SNODENT and additional information that you are seeking to use in your consideration of SNODENT as a core terminology for the PMRI standard.  Second, in a discussion totally unrelated to SNODENT, the PMRI standard, or any diagnostic taxonomy, I will describe our proposed changes to the maintenance process for the ADA’s Code on Dental Procedures and Nomenclature.  Of course, I would also be happy to answer any questions.


The ADA appreciates the opportunity to be able to provide information to assist the Committee resolve the identified content issues related to recommending SNODENT (A Systemized Nomenclature of Dentistry) as a core terminology for the Patient Medical Record Information (PMRI) standard.  We understand you are seeking additional information on the relationship between SNOMED CT and SNODENT as well as the maintenance process for SNODENT.

In April 1998, the American Dental Association entered into a ten-year agreement with the College of American Pathologists (CAP).  The ADA wanted to create, publish and distribute a systematized nomenclature of dentistry containing dental diagnoses, signs, symptoms and complaints to be known as SNODENT, using in part content contained in SNOMED V3.4.  In 1999, the ADA completed the copyrighted work, SNODENT, which is a compilation of dental terms and codes, specially selected, organized and arranged by the ADA for use by the dental profession.  Through that agreement, the CAP was licensed to incorporate the entire nomenclature of dentistry (SNODENT) into SNOMED and to assign SNOMED codes to the SNODENT terms.

Since that time, the dental content in SNOMED V3.5 was transformed into the SNOMED CT structure, complete with semantic definitions for each dental concept.  In addition, the dental content of SNOMED CT was enriched through the addition of the dental content contained in the U.K.:place>:country-region>’s Clinical Terms V.3, which was merged with SNOMED RT to create SNOMED CT.  To provide continuing collaboration, the American Dental Association maintains a liaison to the SNOMED International Editorial Board.

The maintenance process for SNODENT is similar to that for SNOMED.  The Advisory Committee on Dental Electronic Nomenclature, Indexing and Classification (ACODENIC) of the ADA:City> will process all suggestions concerning changes to SNODENT and forward recommendations for modifications to the Council on Dental Benefit Programs of the ADA for approval.  The ACODENIC is made up of representatives from all the recognized dental specialty organizations and the ADA.  The ADA is working to include payer representation on this committee.  Our Council on Dental Benefit Programs is involved in this process and we expect to complete this in April.

ACODENIC will actively seek and accept recommendations, comments and suggestions from all parties that have an interest in SNODENT in an open process, including accepting electronic input at  Public input is circulated to the ACODENIC for comment and face-to-face meetings are scheduled to discuss any proposed additions, deletions and modifications.  Any recommendations the ACODENIC makes for changes to SNODENT are forwarded to the Council on Dental Benefit Programs.  Changes to SNODENT approved by the Council are then taken to the SNOMED International Editorial Board for consideration of inclusion in SNOMED.

The ADA has developed SNODENT as a standard that would become an integral component of an electronic health record for dentistry.  Adoption of the electronic health record depends on the designation of codified vocabulary accepted by the practitioners.  We urge the NCVHS to designate SNODENT as the core terminology for dentistry in the patient medical record for the reasons we have previously enumerated to encourage its use by the profession.

We are grateful for the Subcommittee’s extensive efforts to identify and recommend core terminologies and allowing the ADA to provide information.  We look forward to your further consideration of SNODENT.

The ADACode on Dental Procedures and Nomenclature

Unlike diagnostic codes, which have never been a component of dental transactions, this procedure Code is a long-standing mechanism for dentists’ reporting dental treatment provided.  Its maintenance is accomplished by a legally binding, court-approved settlement agreement between the ADA and the Delta Dental Plans Association (DDPA).  That agreement clearly spells out exactly how changes in the procedure Code can be made.  The ADA has modified its Code revision process to accommodate the requirements of the settlement agreement and has rigorously abided by its terms.

That settlement requires that a Code Revision Committee be established, which is an entity with representation from dentists and third-party payers, and a national purchaser of dental benefits, to consider requested changes to the Code on Dental Procedures and Nomenclature.  Any changes to the settlement agreement must be agreed upon by all signatories to that agreement.

As the nature of the dental benefits industry has changed, much like the changes seen in the medical-surgical-hospital benefits industry, new market forces have emerged.  A relatively new organization of payers has emerged that presents a substantial portion of the dental benefits industry, the National Association of Dental Plans (NADP).  Recognizing this changed dental benefits environment, the ADA:City> has recommended that the Code Revision Committee be expanded to include a representative from NADP and another representative from the ADA:place>:City> to maintain balanced representation.  To date, this proposal has not been accepted by the DDPA.  We are hopeful that agreement on this change can be reached soon.

Recently, some payers have recommended that several procedure code modifiers be added to the procedure Code that are, in fact, diagnoses.  This expansion of the procedure Code into the area of diagnosis by the inclusion of an extremely limited number of diagnoses in the form of procedure modifiers was considered by a special ad hoc workgroup of the CRC.  That workgroup recommended that the CRC defer action on these requests in light of the emergence of SNODENT, and that the Committee monitor further developments in this area.

Adding diagnostic information in the form of procedure code modifiers to replace local codes and reflect the specific needs of individual dental benefit plans would not result in a net administrative simplification, and would thwart the HIPAA goals of standardization of transactions and code set regulations.  This would delay or prevent the migration of a great number of dentists from paper claims to electronic claims submission.

Let me conclude this discussion of the ADA procedure Code by expressing our appreciation to the Subcommittee for its interest in learning how the ADA is working to bring the various dental communities of interest together in resolving dental transaction concerns.  We believe those involved in dental transactions on a day-to-day basis are best equipped to resolve problems as they present themselves.

Finally, in addressing the main business at hand, a dental diagnostic taxonomy for the electronic health record, let me thank the Subcommittee for the time and effort it has expended in considering SNODENT as the core dental terminology and express again the desire of the ADA:place>:City> that the Subcommittee make that recommendation to the Secretary.

I would be pleased to answer any questions the Subcommittee members may have.