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5

100+ Questions 2011-2012


and Answers on the
Code, Claim Form
and Adjudication
CDT
Current Dental Terminology
5

100+ Questions and Answers on the Code, Claim Formand Adjudication


100+ Questions and Answers
on the Code, Claim Form and
Adjudication

The Questions and Answers (Q&A) in this publication have been prepared by the ADA
Council on Dental Benefit Programs and are intended to assist a dentist or practice staff
in determining the procedure code that is most appropriate to describe the service
provided. These Q&A complement, but are not part of, the Code on Dental Procedures
and Nomenclature (Code) that is published in Section 1 of this CDT manual. Q&A are not
to be considered legal advice or a guarantee that individual payer contracts will follow
this assistance.
Questions and their answers on the Code in the following pages are distributed across
the twelve categories of service (e.g., Diagnostic; Restorative). Where appropriate,
some Q&A’s are grouped within a subcategory of service. Each of the questions and
their answers reflects actual inquires from dentists and their staff.

Selecting a Procedure Code


When determining which dental procedure code should be used to document services
provided to a patient, please consider the Code’s complete entries as published
in the current edition of the “CDT” manual. These entries consist of the alphanumeric
procedure code with its nomenclature and descriptor. Alphanumeric procedure codes
(e.g., D0150) and their nomenclature are printed in boldface type; descriptors are in
regular typeface.
If after reviewing all components of a full procedure code entry you determine that there
is no specific procedure code that is applicable to the service, it may be appropriate to
use an “unspecified procedure by report” code, also known as a “999” code. Such codes
are included for each category of dental services, with the exception of Preventive
services. All “by report” procedure codes are expected to include a supporting
narrative that explains the service provided.
Please note that dental benefit plan coverage limitations and exclusions, and where
applicable the provisions of a participating provider agreement, affect third-party
payer claim adjudication.

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100+ Questions and Answers on the Code, Claim Formand Adjudication


Diagnostic (D0100 – D0999)

Clinical Oral Evaluations

1. When is it appropriate to report a consultation versus an evaluation


procedure?
Typically, a consultation (D9310) is reported when one dentist refers a patient to
another dentist for an opinion or advice on a particular problem encountered by
the patient.

2. Should a specialist who sees patients referred by a general dentist for an


evaluation of a specific problem report code D0140, D0160 or D9310 for
the evaluation? Does it matter if the specialist initiates treatment for the
patient on the same visit?
Code D9310 may be used when a patient is referred to another dentist for
evaluation of a specific problem. The dentist who is consulted may initiate
therapeutic services for the patient.
Code D0140 and D0160 are both problem focused evaluations. D0160 should
be used when the evaluation is detailed and extensive and based on the findings
of a comprehensive evaluation.

3. What are the codes for an initial exam and an emergency exam?
A series of clinical evaluation codes exist that recognize the cognitive skills
necessary for patient evaluation. Codes D0120 through D0180 are available
to report patient evaluations, depending on the nature of the service provided.
Please refer to the code’s nomenclature and descriptor to assist your decision
making process.
The initial examination for a new patient may be reported using “D0150
comprehensive oral evaluation – new or established patient” or by “D0180
comprehensive periodontal evaluation – new or established patient.” An
examination of a patient who presents with a dental emergency may be reported
using “D0140 limited oral evaluation – problem focused.”

4. Can I submit a periodic evaluation (D0120) on the same day as a full mouth
debridement to enable comprehensive periodontal evaluation and diagnosis
(D4355)?
There is nothing in the descriptors of the oral evaluation code or D4355 that
preclude reporting on the same day. Some benefit plans have limitations or
exclusions about paying for both of these procedures on the same day.

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100+ Questions and Answers on the Code, Claim Form and Adjudication

5. May I submit a ‘limited oral evaluation’ (D0140) and another procedure on


the same day?
There is no language in the descriptor of D0140 that precludes the reporting
of other procedures on the same date of service. However, some benefit plans
have limitations or exclusions about paying for certain combinations of codes
performed on the same day.

6. May I report “D0170 re-evaluation – limited, problem focused (established


patient; not post-operative visit)” for a periodontal re-evaluation?
There is no code for a periodontal re-evaluation. Procedure code D0170 may
be reported when not monitoring post-operative tissue healing. Code “D4999
unspecified periodontal procedure, by report” is also an available code to report
a periodontal re-evaluation.

7. We recently had a patient come in for a periodic oral evaluation. The
doctor found signs and symptoms of periodontal disease and performed
a complete periodontal evaluation. May I report both the periodic and
periodontal evaluations, since these are two separate procedures?
The comprehensive periodontal procedure includes all of the components of a
periodic evaluation, and adds additional requirements for periodontal charting and
the evaluation of periodontal conditions. When a patient presents with signs or
symptoms of periodontal disease, and all of these components were performed,
D0180 would be reported.

8. Is reporting the ‘comprehensive periodontal evaluation’ (D0180) limited to


Periodontists?
D0180 is not limited to Periodontists. All dental procedure codes are available
to any practitioner providing service within the scope of her or his license.

9. I have read the descriptors of the evaluation codes, but am confused as to


which code should be reported when a very young child is evaluated in the
office. None of them seem to apply. What should be reported?
The procedure code for the evaluation of a child under age three and including
counseling of the child’s primary caregiver may be reported. This code is: “D0145
oral evaluation for a patient under three years of age and counseling with primary
caregiver.”

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100+ Questions and Answers on the Code, Claim Formand Adjudication


10. Can code D0145 be reported every time the child comes into the office for
an evaluation, or should we report a recall evaluation for subsequent visits?
A separate evaluation code was added because of the unique procedures that are
necessary when evaluating a very young child. Depending on the nature of the
evaluation, a periodic evaluation (D0120) or an oral evaluation for a patient under
three years of age (D0145) would be appropriate choices to consider.

Radiographs/Diagnostic Imaging

11. Are a panoramic films and bitewings considered a full mouth series of
radiographs?
No, a panoramic film and bitewings are not the same as the “D0210 intraoral,
complete series…” procedure. According to the FDA’s “The Selection of Patients
for Dental Radiographic Examinations” published in 2005, a full mouth series is
defined as “A set of intraoral radiographs usually consisting of 14 to 22 periapical
and posterior bitewing images intended to display the crowns and roots of all
teeth, periapical areas and alveolar bone crest.” Effective January 1, 2009 this
definition was incorporated into the D0210 descriptor.
Further, a panoramic film cannot be considered a full mouth series as it is an
extraoral film and it does not reflect the FDA definition of a full mouth series.
Different procedure codes are available to report a full mouth series (D0210)
and a panoramic film (D0330). Please note that bitewings taken as part of a
full mouth series are not reported separately.

12. There are procedure codes for one, two and four bitewings, but no code
for three bitewings. How do I report three bitewing x-rays?
A procedure code to report three bitewing images was approved by the Code
Revision Committee effective January 1, 2007. You may report procedure code
“D0273 bitewings, three films.”

13. Our office has begun to use new technology that provides 3-D or 2-D images
of a patient that are generated from a CT-like scan. How do we code this?
Three procedure codes are available. To report the patient visit when the images
are taken, use code “D0360 cone beam ct – craniofacial data capture.”
If a traditional two dimensional view is produced, such as a panoramic image or
lateral skull, report “D0362 cone beam – two dimensional image reconstruction
using existing data, includes multiple images.”
When a three-dimensional view is generated, use code “D0363 cone beam – three
dimensional image reconstruction using existing data, includes multiple images.”

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14. When we reconstruct images on a certain date, I understand we only report


it once for all of the 2-D images, and once for all 3-D images. If we have
to reconstruct a new image or view from existing data at a different
date, perhaps for another dentist, do we report the data capture and
reconstructions again?
The appropriate image reconstruction code should be reported. Since the data
capture has already been reported it would not be appropriate to report it again.

Tests and Examinations

15. Is a caries susceptibility test (D0425) the same as a caries detectibility
test?
No, they are different procedures. A caries susceptibility test is a diagnostic test
for determining a patient’s propensity for caries. There is no procedure code for
a caries detectibility test, which aids in determining the presence of caries.
“D0999 unspecified diagnostic procedure, by report” may be used to report a
caries detectibility test.

16. Can I submit a code for pulp vitality tests or is this considered to be
included in all endodontic procedures?
Yes, you may submit this as a separate service (D0460) as it is a stand-alone
code. It includes multiple teeth and contra lateral comparison(s), as indicated.

17. Our office recently purchased a VelScope and was wondering if there was
a procedure code available?
Procedure codes contained in the Code on Dental Procedures and Nomenclature
as published by the ADA in the CDT manual are not product or brand-name
specific. Devices such as the VelScope may be used in the delivery of procedures
such as: “D0431 adjunctive pre-diagnostic test that aids in detection of mucosal
abnormalities including premalignant and malignant lesions, not to include
cytology or biopsy procedures.”

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100+ Questions and Answers on the Code, Claim Formand Adjudication


Preventive (D1000 – D1999)

Dental Prophylaxis

1. What is the definition of prophylaxis?


A prophylaxis is removal of plaque, calculus and stains from the tooth structures.
It is intended to control local irritational factors.

2. Does the patient’s age dictate whether a child or adult prophylaxis is


reported?
The prophylaxis codes are dentition specific rather than age specific.
However, third-party payers may have age restrictions in their contracts that
determine the level of benefits available. The ADA’s House of Delegates has
adopted a policy concerning this question:
Age of “Child” (1991:635)
 esolved, that when dental plans differentiate coverage based on the
R
child or adult status of the patient, this determination be based on clinical
development of the patient’s dentition, and be it further
 esolved, that where administrative constraints of a dental plan preclude
R
the use of clinical development so that chronological age must be used
to determine child or adult status, the plan defines a patient as an adult
beginning at age 12 with the exclusion of treatment for orthodontics
and sealants.

3. What code do I utilize for a difficult prophylaxis?


There is no separate procedure code that reflects the degree of difficulty of a
dental prophylaxis. The available prophylaxis codes are “D1110 prophylaxis –
adult” and “D1120 prophylaxis – child”.

4. How do I document cleaning a complete fixed denture or a removable


partial prosthesis?
According to third-party payer members of the Code Revision Committee
“D1110 prophylaxis – adult” would be used to document and report this service.

5. What code do I use to report a cleaning in the presence of gingival


inflammation?
The descriptors of the prophylaxis codes (“D1110 prophylaxis – adult” and “D1120
prophylaxis – child”) include removal of factors that cause local irritations. When bone
loss is present, other procedures may be appropriate to control disease factors.

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6. Can “D1110 prophylaxis-adult” and “D4342 scaling and root planing one
to three teeth per quadrant” be reported on the same date of service?
There is no language in the descriptor of an adult prophylaxis that precludes
the reporting of any other procedure. Some benefit plans have limitations or
exclusions about paying for both these procedures on the same day.

7. Our office has received EOB’s from insurance companies indicating that
the combination prophy/fluoride codes (D1201-child, D1205-adult) are
no longer valid. What are the new combination codes?
The Code does not contain combination prophy/fluoride procedure codes.
Effective January 1, 2007 a prophylaxis and a fluoride treatment are reported
as two separate procedures. For a child codes “D1120 prophylaxis – child” and
“D1203 topical application of fluoride-child” may be reported. For an adult codes
“D1110 prophylaxis – adult” and “D1204 topical application of fluoride – adult”
may be reported.

Topical Fluoride Treatment

8. I see that there is a code for placing fluoride varnish. May I use this code
when applying varnish to desensitize a tooth?
When fluoride varnish is utilized to desensitize a tooth, you may report “D9910
application of desensitizing medicament”. Procedure code “D1206 topical
fluoride varnish; therapeutic application for patients at moderate to high risk
of developing caries” is used for therapeutic purposes with patients who are at
moderate to high risk of developing caries.

9. If our office uses fluoride varnish as part of our recall visit protocol should
I report codes D1203 or D1204 as we have done in the past, or should I
use the new fluoride varnish code?
The procedure codes you have used in the past for preventive topical fluoride
(D1203 and D1204) do not specify the formulation or technique used for
application. Procedure code D1206 should be reported for the therapeutic
application of fluoride varnish for patients with moderate to high risk of caries
development.

10. Is it necessary to use trays to deliver fluoride treatment in the office?


The Code does not specify delivery mechanisms for topical fluoride materials.
This aspect of the procedure is best determined by the practitioner at the time
of service.

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100+ Questions and Answers on the Code, Claim Formand Adjudication


11. What is meant by delivery of a fluoride treatment “…under the direct
supervision of a dental professional?”
All dental professionals should deliver services according to applicable state laws
and within the scope of their licensure. “Direct supervision…” would be defined by
state practice acts; contact your constituent or component dental society for such
information.

Other Preventive Services

12. What code do I use to report a fissurotomy?


The term “fissurotomy” is actually a trademarked name and applies to a particular
kind of bur. However, “fissurotomy” is sometimes used to describe a technique
utilizing the mechanical enlargement of occlusal pits and fissures. In that situation
you could use “D9971 odontoplasty 1-2 teeth; includes removal of enamel
projections.”

13. When using resin, what distinguishes a sealant from a preventive resin
restoration?
The Code was revised effective January 1, 2011 to enable separate reporting of
these distinct procedures. Resin used as a sealant in a pit and fissure area, limited
to the enamel, would be documented using D1351. When resin is used in a pit and
fissure area where there is an active cavitated lesion that does not extend into the
dentin, the available procedure code is D1352 (added effective January 1, 2011).
Should the lesion extend into the dentin, the procedure code for one surface
composite resin restoration (D2391) would be used to document the service.
As always, the full procedure code nomenclature and descriptor must be used to
determine which Code entry is applicable.
D1351 sealant - per tooth
Mechanically and/or chemically prepared enamel surface sealed to
prevent decay.
D1352 preventive resin restoration in a moderate to high caries risk
patient – permanent tooth
Conservative restoration of an active cavitated lesion in a pit or
fissure that does not extend into dentin; includes placement of
a sealant in any radiating non-carious fissures or pits.
D2391 resin-based composite – one surface, posterior
Used to restore a carious lesion into the dentin or a deeply eroded
area into the dentin. Not a preventive procedure.

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100+ Questions and Answers on the Code, Claim Formand Adjudication


Restorative (D2000 – D2999)

1. How may I report local anesthesia as a separate procedure?


“D9215 local anesthesia in conjunction with operative or surgical procedures”
is an available procedure code if you wish to report it separately. Benefit plan
limitations may preclude separate reimbursement for local anesthesia.

2. I know there are no differences between primary teeth and permanent


teeth for most indirect restorations. Are there direct restorative codes
for primary teeth?
The codes listed under the direct restorative category of service include both
the primary and permanent dentitions.

3. How do I report two separate 2-surface restorations on the same tooth?


Carriers advise me to report a MO amalgam and a DO amalgam as a MOD
restoration. Is this correct?
Dentists should report the procedures performed, and reporting these restorations
separately as a MO and a DO is appropriate. Dental plans may have clauses that
restrict coverage on the same surface twice on the same date of service. This is
why some carriers may apply an alternate benefit provision that recodes the two
separate restorations as a single restoration.

4. I recently purchased a laser and have been unable to find any “laser” codes
in the Code on Dental Procedures and Nomenclature.
The codes are procedure based rather then instrument based. You would report
the appropriate code based on the actual procedure that was performed.

Resin-based Composite Restorations

5. What code do I report for an incisal restoration?


If the restoration involves the incisal angle, code “D2335 resin-based
composite – four or more surfaces or involving incisal angle (anterior)” may be
reported. If the incisal surface restored does not involve the incisal angle, report
with the appropriate anterior procedure code that describes the number of
surfaces restored.

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100+ Questions and Answers on the Code, Claim Form and Adjudication

Crowns – Single Restorations Only

6. Should single crowns that are splinted together be coded as single crowns
(in the D27xx series of codes) or as a bridge (in the D67xx series)?
Single crowns that are splinted together are appropriately reported as single
crowns, D27xx. There is no coding mechanism to report splinting the crowns.
Prosthodontic retainers are parts of a fixed partial denture that attach a pontic
to the abutment tooth, implant abutment, or implant and should be used in
conjunction with a pontic code.

7. What procedure code should I report for a porcelain fused to a zirconium


substrate crown?
The available procedure code is “D2740 crown – porcelain/ceramic substrate.”

8. How do I code a porcelain fused to titanium crown? I only see a code for
titanium code D2794 crown - titanium.
“D2794 crown – titanium” is the only titanium crown procedure available.

Other Restorative Services

9. Is there a code for retrofitting a new crown to an existing partial denture?
The code is “D2971 additional procedures to construct new crown under existing
partial denture framework” and should be reported in addition to the crown.

10. Is there a procedure code for recementing an onlay?


Code “D2910 recement inlay, onlay, or partial coverage restoration” includes the
recementation of an inlay, onlay or any other partial coverage restorations such
as a veneer.

11. Code “D2970 – temporary crown (fractured tooth)” was deleted from the
version of the Code published in CDT-2005. What code is the replacement
for D2970?
The Code Revision Committee reinstated a revised code D2970 effective
January 1, 2007 and published in the CDT manual.

12. If I place an IRM (Intermediate Restorative Material) restoration, do I


report this as sedative restoration or a palliative procedure?
Both sedative filling (D2940) and palliative (emergency) treatment of dental
pain (D9110) may be applicable depending on the dentist’s clinical judgment.
However, one would not code both simultaneously for the same procedure.

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100+ Questions and Answers on the Code, Claim Formand Adjudication


13. How is the doctor to report a situation where a restorative (or any other)
procedure is started but not finished?
The current version of the Code does not contain a code for procedures that are
started but not completed (with the exception of D3332 incomplete endodontic
therapy; inoperable, unrestorable or fractured tooth). When services rendered are
not addressed by a specific code, an unspecified procedure, by report code (e.g.,
“D2999 unspecified restorative procedure, by report”) may be used.

14. The patient’s treatment plan includes placement of a prefabricated post and
core under an existing crown. What procedure code would be used to report
this procedure?
There is no code that specifically refers to placement of a prefabricated post and
core under an existing crown. When there is no procedure code whose nomenclature
and descriptor reflect the service provided, an “unspecified…procedure, by report”
code may be considered (e.g., D2999 unspecified restorative procedure, by report).

15. The patient’s treatment plan includes placement of a prefabricated post


without a core. What procedure code would be used to report this procedure?
There is no code that specifically refers to placement of a prefabricated post without
a core. When there is no procedure code whose nomenclature and descriptor reflect
the service provided, an “unspecified…procedure, by report” code may be considered
(e.g., D2999 unspecified restorative procedure, by report).

16. An access cavity was made through a crown for endodontic treatment.
What procedure code is appropriate to report sealing an endodontic
access cavity?
There is no code that specifically refers to placement of a restoration to seal an
endodontic access cavity. When there is no procedure code whose nomenclature
and descriptor reflect the service provided, an “unspecified…procedure, by report”
code may be considered (e.g., D2999 unspecified restorative procedure, by
report). Restorative codes may also be used to report sealing an access cavity.

17. I placed a temporary restoration to protect my patient’s tooth structure


and surrounding tissues. Would “D2940 sedative filling” be appropriate
for reporting this procedure?
There is no code that specifically refers to placement of a temporary restoration
to protect tooth structure and surrounding tissues. When there is no procedure
code whose nomenclature and descriptor reflect the service provided, an
“unspecified…procedure, by report” code may be considered (e.g., “D2999
unspecified restorative procedure, by report”).

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100+ Questions and Answers on the Code, Claim Formand Adjudication


Endodontics (D3000 – D3999)

Pulpotomy

1. What is the code for apexogenesis?


Apexogenesis is vital pulp therapy performed to encourage continued
physiological formation and development of the tooth root. To report this
procedure, use procedure code “D3222 partial pulpotomy for apexogenesis…”
that was added to the Code effective January 1, 2009.

Endodontic Therapy

2. Should I report a root canal procedure on the date the tooth is opened,
or the final fill date?
For clinical record keeping purposes, the initiation date should be recorded.
Some third-party payers require the completion date as the date of service
for an endodontic procedure.

3. If I see a patient on an emergency basis to relieve pain and begin a root
canal procedure on tooth # 31, but do not finish it on the same day, may
I code D3221 on the initial visit and later code the root canal procedure
(D3330)?
Language in the descriptor of pulpal debridement (D3221) precludes the same
provider from reporting this procedure on the same date as an endodontic
procedure. Since the date of completion of the root canal is different from the
date of initiation of the procedure, and the patient presented with an emergency,
both codes may be reported.

4. What code do I use to report root canal therapy on a molar with 4 canals
since it requires more work than a typical molar with three roots?
Endodontic therapy is reported based on the anatomic type of the tooth, not
number of canals. Code “D3330 endodontic therapy, molar (excluding final
restoration)” should be reported for a molar root canal therapy.

5. May I report code “D3331 treatment of root canal obstruction; non-surgical


access” and D3330 (root canal therapy on a molar) on the same day?
There is nothing in either codes’ nomenclature or descriptor that says these two
cannot be reported on the same day.

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6. May I report “D3331 treatment of root canal obstruction…” and “D3348


retreatment of previous root canal therapy - molar” when an endodontic
molar retreatment involves removing separated instruments or carriers
for filling material?
There is no language in the descriptor of D3331 that precludes the reporting of
any initial or retreatment endodontic codes on the same date of service.

7. Does an endodontic procedure include an exam and diagnostic X-rays?


The descriptor for the Endodontic Therapy subcategory of service that contains
endodontic procedures D3310, D3320, and D3330 states that these procedures
do not include diagnostic evaluation and necessary diagnostic radiographs/images.
It is appropriate to report an evaluation or diagnostic radiographs/images when
clinical circumstances dictate these procedures are necessary.

Apicoectomy/Periradicular Services

8. How can I report a procedure performed to determine if a root was


fractured?
Codes in the Endodontics subcategory “Apicoectomy/Periradicular Services” can
be used to report this procedure. The codes are differentiated by type of tooth
and number of roots involved in the surgical service.

9. If I perform an apicoectomy and submit tissue for a biopsy on tooth #10,
how do I code for these procedures?
Submission of tissue for biopsy is not included in the subcategory descriptor as
a component of an apicoectomy procedure. There are no biopsy codes available
to report tissue collection during an apicoectomy procedure. The descriptor of
“D7286 biopsy of oral tissue – soft” prohibits its use at the same time as codes
for apicoectomy/periradiucular surgery. An available code is “D9999 unspecified
adjunctive procedure, by report”. Plan limitations may exclude or not recognize
certain combinations of codes performed on the same day.

Other Endodontic Procedures

10. I am a dentist in general practice and my patient has a tooth that needs
endodontic retreatment, which will be provided by an endodontist after
I remove the post. What procedure code is appropriate to report only
removal of the post?
“D2955 post removal (not in conjunction with endodontic therapy)” may
be reported because the post removal is by a different practitioner than the
retreating dentist.

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100+ Questions and Answers on the Code, Claim Formand Adjudication


Periodontics (D4000 – D4999)

Surgical Services

1. What is the code for using a laser?


A laser is an instrument and can be used in many dental applications. The dental
procedure codes are procedure based rather than instrument based. For example,
if a gingivectomy on tooth 8 was performed using a scalpel or a laser, the
procedure code would be the same – “D4211 gingivectomy or gingivoplasty –
one to three teeth or bounded teeth spaces per quadrant.”

2. What code do I report for gingival curettage?


There is no specific procedure code to report gingival curettage. If a flap
procedure was performed, curettage may be reported as code “D4240 gingival
flap procedure, including root planing – four or more contiguous teeth or tooth
bounded spaces per quadrant” or “D4241 gingival flap procedure, including root
planing – one to three teeth, per quadrant”. The descriptors of these codes
include open flap curettage and the removal of granulation tissue following the
resection or reflection of a soft tissue flap.
If a flap procedure was not performed, procedure codes for periodontal scaling
and root planing, D4341 or D4342, should be considered. If the treating dentist
does not feel that the descriptors for D4240, D4241, D4341 or D4342
adequately describe the procedure performed, “D4999 unspecified periodontal
procedure, by report” is an available code to report the curettage.

3. Can I report a full mouth debridement to enable comprehensive evaluation


and diagnosis on the same day as a comprehensive oral or periodontal
evaluation?
An initial assessment of the patient may have been conducted before this procedure
is performed. The balance of the comprehensive evaluation should be performed
after the debridement procedure. There is no language in the descriptor of “D4355
full mouth debridement to enable comprehensive evaluation and diagnosis” that
precludes the reporting of other procedures on the same date of service. However,
plan limitations may exclude or not recognize certain combinations of codes
performed on the same day.

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100+ Questions and Answers on the Code, Claim Form and Adjudication

4. The nomenclatures for several periodontal surgical codes refer to “four or


more contiguous teeth or tooth bounded spaces per quadrant” or “one-to
three teeth or tooth bounded spaces per quadrant.” What is an example of
a tooth bounded space?
The definition of “tooth bounded space” was added to the Periodontal category of
service in the version of the Code effective January 1, 2009 and reads as follows:
“A space created by one or more missing teeth that has a tooth on each side.”
Example: The patient is missing teeth 4 and 5. Osseous surgery is performed
on teeth 2, 3 and 6. The edentulous area between 3 and 6 is considered a
tooth bounded space. A full quadrant code is appropriate (i.e., “…four or more
contiguous teeth or tooth bounded spaces…”) for this example.

5. What is the code for reporting Platelet Rich Plasma?


Platelet Rich Plasma is a concentrated suspension of the growth factors found
in platelets. Since it is a biologic material, it may be reported using code “D4265
biologic materials to aid in soft and osseous tissue regeneration.”

6. Can D1110 (adult prophylaxis) and D4342 (scaling and root planing one to
three teeth) be reported on the same date of service?
There is nothing in either codes’ nomenclature or descriptor that says these two
cannot be reported on the same day. However, many benefit plans are designed
not to allow payment of benefits for these procedures when reported on the
same date of service.

7. We use the bone replacement graft codes D4263 and D4264 in periodontal
defects around and adjacent to natural teeth. Do we use the same codes in
periodontal defects around existing endosseous implants?
There is nothing in either code’s nomenclature or descriptor that says these two
cannot be used to report grafts around existing endosseous implants. Should a
dentist, after considering nomenclatures and descriptors, determine that neither
code appropriately describes the service provided an ‘unspecified procedure,
by report’ code may be used (e.g., “D4999 unspecified periodontal procedure,
by report”).

8. We use the bone replacement graft code D7953 when placing graft
material in an extraction socket when we remove a natural tooth. But
if we place an immediate implant in the extraction site and place bone
graft around the implant, do we still use D7953 or do we use one of the
periodontal bone graft codes D4263 or D4264?
The nomenclature for D7953 indicates that this procedure code is appropriate
to report when the service is for ridge preservation, and this code’s descriptor

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100+ Questions and Answers on the Code, Claim Formand Adjudication


also makes reference to preservation of ridge integrity “…clinically indicated in
preparation for implant reconstruction….” There is no specific reference to ridge
preservation in either the nomenclatures or descriptors for D4263 or D4264.

9. If we remove an existing implant and place bone replacement graft in the
site, can we still use the D7953 code?
The descriptor for D7953 states that the graft “…is place in an extraction site
at the time of extraction….” This indicates that “D7953 bone replacement graft
for ridge preservation - per site” may not be appropriate to report the service as
described because the literal definition of extraction applies to a tooth.
When a dentist determines, after considering nomenclatures and descriptors,
no code appropriately describes the service provided an “unspecified…procedure,
by report” code may be used (e.g., “D7999 unspecified oral surgery procedure,
by report”).

10. The dental hygienists in our office are using Oraqix prior to scaling and root
planing. How would Oraqix be reported?
The Periodontics category of service indicates that “Local anesthesia is usually
considered to be part of Periodontal procedures.” However, there is nothing to
prevent reporting the use of Oraqix to anesthetize the patient with procedure
code “D9215 local anesthesia in conjunction with operative or surgical
procedures.” Benefit plan limitations may exclude separate reimbursement for
local anesthesia.

Non-Surgical Periodontal Service

11. How do I report placing a slow–release antibiotic or a chemotherapeutic


agent into a periodontal pocket?
Code “D4381 localized delivery of antimicrobial agents via a controlled release
vehicle into diseased crevicular tissue, per tooth, by report” may be reported.

12. What code do I submit for Arestin, Actisite or Perio Chips?


Code “D4381 localized delivery of chemotherapeutic agents via a controlled release
vehicle into diseased crevicular tissue, per tooth, by report” should be used.

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Other Periodontal Services

13. After active periodontal therapy and a period of maintenance is it ever


appropriate to report code D1110 (prophylaxis) for recall visits?
This is a matter of clinical judgment by the treating dentist. Benefit design should
not guide the clinical determination of procedure performed. A periodontal
maintenance procedure includes removal of plaque, calculus and site specific
scaling and root planing and follows periodontal therapy. The prophylaxis
procedure includes removal of plaque, calculus and stains and is intended to
control local irritational factors.
Follow-up patients who have received active periodontal therapy (surgical or
non-surgical) are appropriately reported using the periodontal maintenance code
D4910. However, if the treating dentist determines that a patient’s periodontal
health can be augmented with a routine prophylaxis, delivery of this service and
reporting with code D1110 may be appropriate.

14. What code should I use to report periodontal charting?


There is no separate procedure code for periodontal charting. If charting is
being reported as a discrete procedure, code “D4999 unspecified periodontal
procedure, by report” may be reported. Periodontal charting is considered to be
a part of a comprehensive periodontal evaluation (D0180) and may be part of
a comprehensive oral evaluation (D0150).

15. Does “D4910 periodontal maintenance” include an evaluation?


This procedure does not include an evaluation. If one is performed, the type of
diagnostic evaluation should be reported separately.

16. How can I code treatment for a periodontal abscess?


There is no specific code and the individual procedures performed should be
reported. For example, if the abscess was incised report code “D7510 incision
and drainage of abscess – intraoral soft tissue” in addition to codes for any
radiographic studies and oral evaluations. If a minor procedure was performed
and the patient was in pain, you may report code “D9110 palliative (emergency)
treatment of dental pain – minor procedure.”
Definitive periodontal treatments should be reported using the appropriate
periodontal codes. Benefits for definitive treatment may be limited by
predetermined plan frequencies.

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100+ Questions and Answers on the Code, Claim Formand Adjudication


17. What code do I report for irrigation using chlorhexidine following scaling
and root planing?
There is no procedure code whose nomenclature reads “irrigation using
chlorhexidine following scaling and root planing.” In situations where, in the
opinion of the dentist providing the service, there is no specific procedure code
that is applicable to the service, then an “unspecified procedure, by report” can be
used. In this situation, “D4999 unspecified periodontal procedure, by report” may
be reported. All “by report” procedure codes are expected to include a supporting
narrative that explains the service provided.

18. Can “D4910 periodontal maintenance” and “D4342 scaling and root planing
one to three teeth per quadrant” be reported on the same date of service?
The descriptor of code D4910 indicates that it includes site specific scaling and
root planing where indicated. Scaling and root planing performed as part of the
maintenance procedure should not be reported separately. However, if new or
recurring periodontal disease appears at the time of the maintenance procedure,
additional diagnostic and treatment procedures must be considered. Plan limitations
may exclude or not recognize certain combinations of codes performed on the
same day.

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100+ Questions and Answers on the Code, Claim Formand Adjudication


Prosthodontics, removable (D5000 – D5899)

Complete Dentures

1. What is the code for a complete upper denture with a cast metal palate?
Code D5110 (complete denture – maxillary) may be reported. The code is silent
in regard to the type of materials used in fabrication.

Partial Dentures

2. How do I code a flexible partial denture?


Either of the following codes may be reported depending on the arch involved:
“D5225 maxillary partial denture – flexible base (including any clasps, rests and
teeth)” or “D5226 mandibular partial denture – flexible base (including any clasps,
rests and teeth).”

3. What is the code for a Cusil partial denture?


Existing partial denture procedure codes do not differentiate clasping systems.
Available codes include “D5211 maxillary partial denture – resin base…” or
“D5212 mandibular partial denture – resin base….”
If no existing code sufficiently describes the procedure performed, an “unspecified
procedure, by report” can be used. In this case, “D5899 unspecified removable
prosthodontic procedure, by report” may be reported. All “by report” procedures
codes are expected to include a supporting narrative that explains the service
provided.

4. I plan to add teeth and bases to a partial denture, converting it to a tissue


borne and retained provisional full prosthesis. What procedure code or
codes would I use to report this service?
This service may be reported using procedures codes D5810 or D5811 (for
maxillary or mandibular) as appropriate.

5. How do I document cleaning a removable partial prosthesis?


According to third-party payer members of the Code Revision Committee
“D1110 prophylaxis – adult” would be used to document and report this service.

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Interim Prostheses

6. What is a flipper/stayplate and how would it be documented?


A flipper/stayplate is a temporary removable partial denture typically fabricated
out of hard acrylic, the same material used to make a standard complete denture.
Available procedure codes:
D5820 interim partial denture (maxillary)
Includes any necessary clasps or rests
D5821 interim partial denture (mandibular)
Includes any necessary clasps or rests

7. What procedure codes would be appropriate to report retrofitting of an


existing removable full denture to be supported by implants?
The descriptor in code “D5875 modification of removable prosthesis following
implant surgery” includes “modification of an existing prosthesis when the
abutments are placed and retentive elements are placed into the removable
prosthesis, thereby reducing the need for a new prosthesis.” Addition of the
abutments may be reported by code “D6056 prefabricated abutment –
includes placement.”

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100+ Questions and Answers on the Code, Claim Formand Adjudication


Maxillofacial Prosthetics (D5900 – D5999)

1. Is there a code for devices that stop snoring?


The Code on Dental Procedures and Nomenclature does not contain a specific
code for devices that stop snoring (e.g., snore guard). An available code is
“D5999 unspecified maxillofacial prosthesis, by report.”

2. I have a patient that will be receiving radiation to the nasopharyngeal area


and the radio-oncologist has advised that the gingival mucosa and teeth
will be exposed. I have recommended that mandibular and maxillary trays
be made for “home fluoride” application. What would be an appropriate
procedure code for these trays?
For the situation described the dental procedure code that you may wish to
consider is “D5986 fluoride gel carrier” whose descriptor reads as follows:
Synonymous terminology: fluoride applicator. A prosthesis, which covers
the teeth in either dental arch and is used to apply topical fluoride in close
proximity to tooth enamel and dentin for several minutes daily.
Coverage or reimbursement for a reported procedure may be subject to benefit
plan limitations and exclusions.

3. The patient presented with gingival lesions of vesiculobullous autoimmune


diseases. A custom tray was fabricated to deliver topical corticosteroids
to the mucosa. How would the tray and medication be documented?
Available procedure codes:
D5991 topical medicament carrier
A custom tray fabricated carrier that covers the teeth and alveolar
mucosa, or alveolar mucosa alone, and is used to deliver topical
corticosteroids and similar effective medicaments for maximum
sustained contact with the alveolar ridge and/or attached gingival
tissues for the control and management of immunologically
mediated vesiculobullous mucosal, chronic recurrent ulcerative, and
other desquamative diseases of the gingiva and oral mucosa.
D9630 other drugs and /or medicaments, by report
Includes, but is not limited to oral antibiotics, oral analgesics, and
topical fluoride dispensed in the office for home use; does not
include writing prescriptions.

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100+ Questions and Answers on the Code, Claim Formand Adjudication


Implant Services (D6000 – D6199)

1. What are the differences between an implant supported prosthesis and an


abutment supported prosthesis?
The difference is dictated by the manufacturer and by the system used by the
dentist. An abutment-supported prosthesis has a connector (abutment) between
the implant and the prosthesis whereas an implant-supported prosthesis directly
attaches to the implant.

2. How do I code resilient implant attachments (e.g., ERA, ZAAG, Zest) done
in conjunction with an implant overdenture?
A resilient implant attachment may be reported using code “D5862 precision
attachment, by report.” Each set of male and female components should be reported
as one precision attachment. The type of attachment used should be described.
If one of the components (male or female) is an integral part of an abutment,
the applicable implant abutment procedure code (e.g., D6056, D6057) may be
reported in addition to “D5862 precision attachment, by report.

3. There are no pontic codes in the Implant category of the Code. When
reporting a fixed partial denture placed on implants, how do I report a pontic?
Pontic codes, found in the Fixed Prosthodontic category of the Code, can be used
with both implant and Fixed Prosthodontic retainer codes. All pontic codes begin
with D62xx.

4. What procedure codes would be used to report a three-unit, implant


supported bridge with custom abutments (porcelain over high noble metal)
at tooth numbers 29 and 31?
There are three procedure codes that would be used to report this service.
For tooth numbers 29 and 31 report “D6057 custom abutment – includes
placement’ and “D6069 abutment supported retainer for porcelain fused to
metal FPD (high noble metal).” For the pontic at tooth number 30, the applicable
procedure code would be “D6240 pontic – porcelain fused to high noble metal.”

5. I have searched the Implant Services Category of service for ERA


attachments for an implant retained prosthesis we are fabricating, but
can only find a code “D6091 replacement of semi-precision or precision
attachment (male or female component) of implant/abutment supported
prosthesis, per attachment” How do we report the initial attachments?
The procedure code for initial attachment is in the Prosthodontics, (removable)
category of service: “D5862 precision attachment, by report.” If one of the
components is an integral part of an abutment, the applicable implant abutment
procedure code (e.g., D6056) would be reported.
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6. I have placed provisional crowns on four implants to allow time


for healing. I find provisional crowns under the Restorative and
Prosthodontics, fixed categories of service, but not in Implant
Services. How should the provisional crowns on the implants be
reported?
The Code on Dental Procedures and Nomenclature does not contain
a specific code for a provisional crown place on an implant. You may
consider using the provisional crown codes D2799 or D6793, but there
may be payer adjudication issues (e.g., crown in an edentulous area)
that could result in claim delay or denial. When a dentist determines that
there is no code whose nomenclature and descriptor adequately describe
the service provided an ‘unspecified procedure, by report’ code may be
reported (e.g., “D6199 unspecified implant procedure, by report”).

Pre-Surgical Services

7. How do I code radiographic implant mapping or an implant template


guide?
Code “D6190 radiographic/surgical implant index, by report” may be
reported.

8. A patient is having endosteal implants placed. A stent like appliance


will be used as a guide while the implants are surgically placed.
Would the appliance be documented as D5982 surgical stent, or
D6190 radiographic/surgical implant index, by report?
Available procedure code:
D6190 radiographic/surgical implant index, by report
An appliance, designed to relate osteotomy or fixture
position to existing anatomic structures, to be utilized
during radiographic exposure for treatment planning and/
or during osteotomy creation for fixture installation.

Surgical Services

9. Code “D6020 – abutment placement or substitution: endosteal


implant” has been deleted. What procedure code replaced D6020?
The implant abutment code nomenclatures were revised at the same time
D6020 was deleted to note that placement was included. As of January 1,
2005 their nomenclatures are “D6056 prefabricated abutment – includes
placement” and “D6057 custom abutment – includes placement.”

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100+ Questions and Answers on the Code, Claim Formand Adjudication


Other Implant Services

10. We have several patients that have implant supported mandibular complete
dentures. What procedure code would be used to report cleaning of the
implants?
Procedure code “D6080 implant maintenance procedures, including removal of
prosthesis, cleansing of prosthesis and abutments and reinsertion of prosthesis”
in the Code on Dental Procedures and Nomenclature would apply to the situation.
The descriptor for this code reads as follows:
“This procedure includes a prophylaxis to provide active debriding of the
implant and examination of all aspects of the implant system, including the
occlusion and stability of the superstructure. The patient is also instructed
in thorough daily cleansing of the implant.”

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100+ Questions and Answers on the Code, Claim Formand Adjudication


Prosthodontics, fixed (D6200-D6999)

1. How do I document cleaning a complete fixed denture?


According to third-party payer members of the Code Revision Committee
“D1110 prophylaxis – adult” would be used to document and report this service.

Fixed Partial Denture Pontics

2. Is there code for an indirect resin bridge?


When used as the definitive prosthesis, report code “D6205 pontic – indirect
resin based composite” and code “D6710 crown – indirect resin based composite”
for the retainers.

3. I am unable to locate a code for a Cantilever bridge.


There is not a specific code with a nomenclature that reads “cantilever bridge.”
A Cantilever fixed partial denture (FPD or bridge) would be reported as individual
units based on the type of material used in fabrication. For example, a two unit
porcelain fused to high noble metal Cantilever FPD replacing tooth 21 would be
reported as follows:
#21 – “D6240 pontic – porcelain fused to high noble metal”
#22 – “D6750 crown – porcelain fused to high noble metal”

Fixed Partial Denture Retainers – Inlays/Onlays

4. How do I report a Maryland bridge?


Each retainer (wing) would be reported as either “D6545 retainer - cast metal
for resin bonded fixed prosthesis” or “D6548 retainer porcelain/ceramic for
resin bonded prosthesis.”
Any other material used in the fabrication of a Maryland bridge should be reported
using code “D6999 unspecified fixed prosthodontic procedure, by report”. The
pontic is coded separately, according to the material used in fabrication.

5. What percentage of the cusp needs to be covered for a restoration to be


considered an onlay?
An onlay is a restoration that restores one or more cusps and adjoining occlusal
surfaces or the entire occlusal surface and is retained by mechanical or adhesive
means. The percent of cusp covered is not a criterion.

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Other Fixed Partial Denture Services

6. Our office filed a claim for a three unit bridge. One of the abutments needed
a root canal and post and core. The claim was rejected by the payer because
we used code D2952 instead of D6970 to report the post. What is the
difference between the two codes?
The two procedures are identical. The only difference is that one procedure code
is reported when a single crown will be placed (D2952), and the other procedure
code is reported when a fixed bridge will be placed (D6970).

7. What is the code to report sectioning of a fixed bridge?


Procedure code “D9120 fixed partial denture sectioning” may be used to report
this service when a portion of the prosthesis is to remain intact and serviceable
following sectioning. For other situations procedure code “D6999 unspecified
fixed prosthetic procedure, by report’” may be used. All “by report” procedure
codes include a supporting narrative that explains the service provided.

8. Is there a code to recement a Maryland bridge?


Recementing a Maryland bridge may be reported with code “D6930 recement
fixed partial denture.”

9. Are there codes to report recementing a single crown or fixed partial


denture?
Two codes are available, each applicable to a different type of prosthesis.
Code D2920 is used to report recementing a single crown; code D6930 is
used to report recementing a fixed partial denture.

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100+ Questions and Answers on the Code, Claim Formand Adjudication


Oral & Maxillofacial Surgery (D7000 – D7999)

Extractions

1. A patient needed an extraction, and it turned into a very difficult procedure.


The doctor removed most of the tooth, but was unable to remove the entire
root and the patient was referred to an oral surgeon immediately. Is there a
code for a partial extraction?
There are no partial extraction codes available. To report this procedure, use code
“D7999 unspecified oral surgery procedure, by report.”

2. I removed a portion of the patient’s fractured tooth, but not the entire
tooth, to provide immediate relief of pain. How should I report this
procedure?
There is no code that specifically refers to removal of a portion of a fractured
tooth to relieve pain. When there is no procedure code whose nomenclature and
descriptor reflect the service provided, an “unspecified…procedure, by report” code
may be considered (e.g., “D7999 unspecified oral surgery procedure, by report”).

Surgical Extractions

3. How much of the crown needs to be covered by bone to appropriately


report it as either a partially bony or as a completely bony extraction?
The observed clinical condition, considered in conjunction with the descriptors for
procedure codes D7230 and D7240, would be used by the dentist to determine
the appropriate procedure code to report.
D7230 removal of impacted tooth – partially bony
Part of crown covered by bone…
D7240 removal of impacted tooth – completely bony
Most or all of crown covered by bone…
This determination is made based on the clinical evaluation of the treating dentist
and his/her determination of what constitutes “most.” Radiographic images may
not provide enough visual information to determine the extent of bony coverage.

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4. According to its descriptor code “D7241 removal of impacted tooth -


completely bony with unusual surgical complications” can be used for a
completely impacted tooth with an “…aberrant tooth position.” Would a
completely impacted wisdom tooth that is radiographically very close to the
mandibular nerve justify use of this procedure code?
The dentist serving the patient is in the best position to determine whether the
observed clinical condition of the patient’s dentition and the procedure provided
matches a dental procedure code (e.g., D7241). Radiographic images may not
provide enough visual information to determine the extent of bony coverage,
aberrant tooth position or other unusual circumstances.
Should a dentist determine that a specific code does not adequately apply to
the service rendered, we recommend that the service be reported using an
‘unspecified procedure, by report’ code (e.g.; “D7999 unspecified oral surgery
procedure, by report”).

Other Surgical Procedures

5. How do I report a brush biopsy?


A brush biopsy should be reported as “D7288 brush biopsy – transepithelial
sample collection.”

6. Code “D7281 surgical exposure of impacted or unerupted tooth to aid


eruption” has been deleted. What code replaces D7281?
Code “D7280 surgical access of an unerupted tooth” has been revised to include
this procedure and may be reported. If a bracket or device is placed after exposure
to aid in eruption, you may report code “D7283 placement of device to facilitate
eruption of impacted tooth” in addition to code D7280.

7. What is the appropriate code for reporting a supra-crestal fiberotomy?


The available procedure code for reporting a supra-crestal fiberotomy is
“D7291 transseptal fiberotomy, by report.”

Surgical Excision of Soft Tissue Lesions

8. What is a fibroma and how would removal be reported?


A fibroma is a benign tumor composed of fibrous or connective tissue.
Available procedure codes:
D7410 excision of benign lesion up to 1.25 cm
D7411 excision of benign lesion greater than 1.25 cm

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100+ Questions and Answers on the Code, Claim Formand Adjudication


Excision of Bone Tissue

9. How do I code removal of mandibular tori?


If the bony elevations are located lingually, code “D7473 removal of torus
mandibularis” may be reported by quadrant.

10. What is a torus/exostosis and how would removal be reported?


A torus/exostosis is a benign overgrowth of bone forming an elevation or
protuberance of bone. They can form in the patient’s palate, lingual or lateral
aspect of the maxilla or mandible.
Available procedure codes:
D7471 removal of lateral exostosis (maxilla or mandible)
D7472 removal of torus palatinus
D7473 removal of torus mandibularis

Reduction of Dislocation and Management of Other TMJD

11. What is the code for adjustment of a TMJ appliance?


There is no specific procedure code to report “adjustment of a TMJ appliance.”
An available code is “D7899 unspecified TMD therapy, by report.”

Other Repair Procedures

12. What is the difference between code “D4263 bone replacement graft –
first site in quadrant”, code “D7950 osseous, periosteal, or cartilage graft
of the mandible or maxilla – autogenous or nonautogenous, by report” and
code “D7953 bone replacement graft for ridge preservation – per site?”
Code D4263 should be reported when the bone graft is performed to stimulate
periodontal regeneration when the disease process has led to a deformity of the
bone around an existing tooth. Code D7953 should be reported when the bone
graft is placed in an extraction site at the time of the extraction to preserve
ridge integrity. Code D7950 should be reported when the graft is used for
augmentation or reconstruction of an edentulous area of a ridge.

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13. How do I code the use of collagen wound dressing products that promote
hemostasis (blood clotting)?
There is no procedure code for collagen wound dressing products. Use of collagen
may be a component of a procedure such as “D9930 treatment of complications
(post-surgical) – unusual circumstances, by report.” In other circumstances,
depending on the primary procedure performed, code “D7999 unspecified oral
surgery procedure, by report” or “D4999 unspecified periodontal procedure,
by report” may be reported.

14. Sinus lift procedures could be reported using code D7950 as published
in CDT 2005, but I noticed that this procedure was removed when code
D7950 was revised for the version published in CDT 2007/2008.
How can I report a sinus lift procedure?
A new code to report sinus lift procedures was introduced in the version of the
Code effective January 1, 2007 and first published in CDT 2007-2008.
Report code “D7951 sinus augmentation with bone or bone substitutes.”

15. We do implants in our office and don’t always place the grafting material
at the time of a tooth extraction; sometimes it is placed at a later date.
What procedure code would be appropriate to report this service?
Procedure code D7950 may be reported when grafting material is being placed
at any time and when placement is not in an extraction site.

16. The last sentence in the descriptors of codes “D7950 osseous,


osteoperiosteal, or cartilage graft of the mandible or maxilla – autogenous
or nonautogenous, by report” and “D7951 sinus augmentation with bone
or bone substitutes” state that if a barrier membrane is placed, it should be
reported separately. I can’t locate codes for barrier membranes in the Oral
and Maxillofacial Surgery category of service. What are the codes?
Barrier membrane procedure codes are located in the Periodontics category of
service. The available codes are: “D4266 guided tissue regeneration – resorbable
barrier, per site” and “D4267 guided tissue regeneration – nonresorbable barrier,
per site (includes membrane removal).”

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100+ Questions and Answers on the Code, Claim Formand Adjudication


17. What is an operculectomy, and how would it be coded?
In dentistry, an operculum is a small flap of tissue surrounding or partially covering
the back molars and “…ectomy” is a surgical suffix referring to the removal of
something. Therefore, an operculectomy is the surgical removal of a flap of
tissue surrounding a partially erupted or impacted tooth.
Available procedure code:
D7971 excision of pericoronal gingiva
Surgical removal of inflammatory or hypertrophied tissues
surrounding partially erupted/impacted teeth.

18. The dentist performed a frenectomy on a child that had been diagnosed
with ankyloglossia. What is ankyloglossia and how would treatment be
documented?
Ankyloglossia, more commonly referred to as “tongue tied,” is a condition in which
the lingual frenum is short and attached to the tip of the tongue, making normal
speech difficult.
Available procedure code:
D7960 frenulectomy – also known as frenectomy or frenotomy –
separate procedure not incidental to another procedure
Surgical removal or release of mucosal and muscle elements of buccal, labial or
lingual frenum that is associated with a pathological condition, or interferes with
proper oral development or treatment.

19. Prior to the replacement of an ill filling maxillary complete denture, it was
necessary to surgically remove an excess formation of palatal tissue. How
would this procedure be documented?
Available procedure code:
D7970 excision of hyperplastic tissue – per arch

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100+ Questions and Answers on the Code, Claim Formand Adjudication


Orthodontics (D8000 – D8999)

1. I do not understand how to code orthodontic procedures. There are very


few codes, and most of the treatments are very complicated. Can you
explain how to use these codes?
The first step is to determine the scope of orthodontic treatment planned for the
patient. These can be limited, interceptive or comprehensive treatments, and each
are described in its own sub-category descriptor in the Code.
The second step in coding for orthodontic treatment is to determine the patient’s
stage of dentition. Definitions of dentition that are used to classify orthodontic
treatment appear as the category descriptor in the Orthodontic category of the Code.
Once these factors are determined, the procedure code based on the dentition
is used to report all specific treatments that lead to the desired outcome as
determined by the treatment planning of the dentist. When a benefit plan has
provisions for periodic payments toward the treatment plan, periodic treatment
visits may be reported using code D8670.

2. What is the appropriate code for reporting an orthodontic workup?


There is not a single code to report an orthodontic workup. Each procedure
performed should be reported separately, using procedure codes found in other
sections of the Code. Examples include diagnostic radiographs, study models,
photographs, etc.

3. After the dentist has completed the orthodontic workup, we schedule


the patient to return for the case presentation. Is there a code for case
presentation?
Code “D9450 case presentation, detailed and extensive treatment planning”
may be reported provided it was not performed on the same day as an evaluation
and is for an established patient.

4. What is the code for clear aligners such as ClearCorrect™, Invisalign® or


Red White & Blue ®?
There is no unique procedure code for such devices. Orthodontic procedures are
reported based on the practitioner’s diagnosis and treatment plan for the patient.
Depending on the treatment objective and stage of dentition, codes are available
for primary, transitional, adolescent and adult dentitions that are treatment
planned for limited, interceptive or comprehensive orthodontic treatment.

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5. What is the procedure code for placement of a band and loop space
maintainer?
The space maintainer codes are listed under the Preventive category of service.
A band and loop would be reported as “D1510 space maintainer – fixed –
unilateral.”

Other Orthodontic Services

6. What is the intent of code “D8660 pre-orthodontic treatment visit”?


Code D8660 was added to the Code effective January 1, 1995. This code is
intended to report a visit to monitor growth and development before the patient
is ready to begin orthodontic treatment.

7. How is an adjustment to an orthodontic retainer coded?


There is no procedure code for an adjustment to an orthodontic retainer.
An available code is “D8999 unspecified orthodontic procedure, by report.”

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100+ Questions and Answers on the Code, Claim Formand Adjudication


Adjunctive General Services (D9000 – D9999)

Unclassified Treatment

1. May I report “D9110 palliative (emergency) treatment of dental pain –


minor procedure” and another procedure on the same day?
There is no language in the descriptor of D9110 that precludes the reporting of
other procedures on the same date of service. However, benefit plan limitations
may exclude or not recognize certain combinations of codes performed on the
same day.

Anesthesia

2. How may I report local anesthesia as a separate procedure?


Code “D9215 local anesthesia in conjunction with operative or surgical
procedures” is an available code if you wish to report it separately. Benefit plan
limitations may exclude separate reimbursement benefits for local anesthesia.

3. Our office used code D9610 (therapeutic drug injection) to report injection
of sedative agents. As of January 1, 2007 D9610 was revised to prohibit
the reporting of sedative agents. How should the injection of sedative
agents be reported?
Available codes are “D9230 inhalation of nitrous oxide / anxiolysis, analgesia” or
“D9248 non-intravenous conscious sedation.”

Professional Consultation

4. When is it appropriate to report a consultation versus an evaluation


procedure?
Typically, a consultation (D9310) is reported when one dentist refers a patient to
another dentist for an opinion or advice on a particular problem encountered by
the patient.

5. Should a specialist who sees patients referred by a general dentist for an


evaluation of a specific problem report code D0140, D0160 or D9310 for
this evaluation? Does it matter if the specialist initiates treatment for the
patient on the same visit?
Code D9310 may be used when a patient is referred to another dentist for
evaluation of a specific problem. The dentist who is consulted may initiate
therapeutic services for the patient.

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Code D0140 and D0160 are both problem focused evaluations. D0160 should
be used when the evaluation is detailed and extensive, and based on the findings
of a comprehensive evaluation.

5. Should a specialist who sees patients referred by a general dentist for an


evaluation of a specific problem report code D0140, D0160 or D9310 for
this evaluation? Does it matter if the specialist initiates treatment for the
patient on the same visit?
Code D9310 may be used when a patient is referred to another dentist for
evaluation of a specific problem. The dentist who is consulted may initiate
therapeutic services for the patient.
Code D0140 and D0160 are both problem focused evaluations. D0160 should
be used when the evaluation is detailed and extensive, and based on the findings
of a comprehensive evaluation.

Professional Visits

6. If a practitioner treats more than one patient in one nursing home on one
day, is D9410 (house/extended care facility call) reported per patient or
per facility?
The descriptor for code D9410 states that it may be reported in addition to
separate reporting of services provided to a patient seen at the facility. D9410
may be reported for each patient receiving service at the facility on a given day.

7. Is “D9420 hospital or ambulatory surgical center call” to be used for each
patient seen in the facility setting, or is it to be reported once when a dentist
sets a block of time (e.g., half day) aside when several patients may be seen?
The descriptor for D9240 states that services provided to the patient on the date
of service are documented separately. D9420 may be reported for each patient
receiving service at the hospital on a given day.

Drugs

8. Is “D9630 other drugs and/or medicaments, by report” only for medicaments
dispensed in the office for home use, or can this be reported for drugs or
medicaments used in the dental office?
There is some ambiguity in the first part of the descriptor for code D9630, which
reads as follows: “Includes but is not limited to oral antibiotics, oral analgesics
and topical fluoride that are dispensed in the office for home use; ....” Some may
argue that the phrase “…dispensed in the office for home use…” applies only to
topical fluoride. Others may argue that the descriptor means this procedure code

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100+ Questions and Answers on the Code, Claim Formand Adjudication


would be used for any drug or medicament dispensed for home use, but not to
report drugs or medicaments used in the dental office. A dentist should consider
these options when determining the procedure code to report when dispensing
drugs and medicaments for patient use in the office. Should the dentist determine
that D9630 is not appropriate, procedure code “D9999 unspecified adjunctive
procedure” may be considered.

Miscellaneous Services

9. How do I report external bleaching?


Report code “D9972 external bleaching - per arch” or code “D9973 external
bleaching - per tooth” as applicable to the service provided to the patient.

10. Are professional strength at-home teeth whitening and bleaching systems
delivered in the office reportable under code “D9972 external bleaching –
per arch”?
You may report code D9972 as there is no limitation on the material that may
be used to provide the service.

11. Is there a code for relining or repairing an occlusal guard?


Report code “D9942 repair and/or reline of occlusal guard.”

12. After placing an occlusal guard I have patients return for approximately
3-4 office visits, as needed, to adjust the guard. What procedure code
would be used to report visits to adjust the guard?
The Code does not contain a specific code for adjusting an occlusal guard. An
available code would be “D9999 unspecified adjunctive procedure, by report.”

13. Does the “external” in the external bleaching code refer to home bleaching,
and the ‘internal’ in the internal bleaching code refer to bleaching
performed in the office?
“External” refers to the outer surface of a tooth, or the entire arch. “Internal”
refers to bleaching performed inside the pulp chamber of a tooth.

14. Is there a code for air abrasion?


If the procedure delivered is consistent with the nomenclature and descriptor
of D9970, that code may be reported. There is no procedure code specifically
for “air abrasion.”

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15. A patient is having porcelain veneers placed on teeth 6 through 11. The
dentist is having the laboratory make a diagnostic wax-up. What is a
diagnostic wax up and how would it be documented?
A diagnostic wax-up presents the patient with a natural-looking, three dimensional
representation of the final case. Also, through the diagnostic wax –up, the dentist
can obtain a visual understanding of tooth reduction requirements.
Available procedure code:
D9950 occlusal analysis –mounted case
Includes, but is not limited to, facebow, interocclusal records tracings,
and diagnostic wax-up; for diagnostic casts, see D0470.

16. What is occlusal equilibration, and how would it be documented?


Occlusal equilibration, also known as occlusal adjustment, refers to the reshaping
of the occlusal surfaces of teeth to create a harmonious contact relationship
between the upper and lower teeth.
Available procedure codes:
D9951 occlusal adjustment – limited
May also be known as equilibration; reshaping the occlusal surfaces
of teeth to create harmonious contact relationships between
the maxillary and mandibular teeth. Presently includes discing/
odontoplasty/enamalplasty. Typically reported on a “per visit” basis.
This should not be reported when the procedure only involves bite
adjustment in the routine post-delivery care for a direct/indirect
restoration or fixed/removable prosthodontics.
D9952 occlusal adjustment – complete
Occlusal adjustment may require several appointments of varying
length, and sedation may be necessary to attain adequate relaxation
of the musculature. Study casts mounted on an articulating
instrument may be utilized for analysis of occlusal disharmony.
It is designed to achieve functional relationships and masticatory
efficiency in conjunction with restorative treatment, orthodontics,
orthognathic surgery, or jaw trauma when indicated. Occlusal
adjustment enhances the healing potential of tissues affected by
lesions of occlusal trauma.

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100+ Questions and Answers on the Code, Claim Formand Adjudication


17. What is a dry socket and how would treatment be coded?
A dry socket is localized inflammation of the tooth socket following extraction
due to loss of the blood clot with resultant osteitis.
Available procedure codes are:
D9930 treatment of complications (post surgical) – unusual
circumstances, by report
For example, treatment of a dry socket following extraction or
removal of bony sequestrum.
D9910 palliative (emergency) treatment of dental pain – minor
procedure
This is typically reported on a “per visit” basis for emergency
treatment of dental pain.

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100+ Questions and Answers on the Code, Claim Formand Adjudication


Claim Form Questions & Answers

1. We noticed on the ADA’s website (www.adacatalog.org) that there is


a dental claim form for insurance purposes that may be purchased and
downloaded to our office computer. If we download this form are we then
able to complete it on the computer and print out a completed form? Or, is
it a read only form that we would print out and complete manually?
The “downloadable” file enables the purchaser to print unlimited copies, but not
to complete the form on the computer. An electronic version of the form is also
included on the CD-ROM edition of the CDT manual. This version of the form may
be printed and completed manually, or be completed on the computer and then
printed, using the Adobe Acrobat Reader software that is incorporated in the CD.
However, it is not possible to save a form that was completed on the computer
without purchase of Adobe Acrobat Standard software.

Provider Specialty Codes

2. The list of provider specialty codes that is printed on the back of the paper
claim form, and in the detailed claim form completion instructions published
in the CDT manual appears to have two codes that describe a general dentist.
As a general practitioner should I use the code for a Dentist (122300000X)
or the code for General Practice (1223G0001X)?
Provider specialty codes (Item #56A) listed on the form and in the CDT manual
reflect the architecture of this code set. The code for Dentist (G122300000X)
may be used by any practitioner who does not wish to be uniquely identified as in
general practice or in specialty practice. Provider specialty code 1223G0001X is
intended to be used by any dentist who wishes to be identified as one who is in
General Practice.

Medical Benefit Claims

3. I’m filing a claim with my patient’s medical benefit plan. How do I complete
the ADA Dental Claim Form to do this?
Claims filed against a patient’s medical benefit plan do not use the ADA Dental
Claim Form.

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4. What form do I use to file a claim with my patient’s medical benefit plan?
Medical benefit plan claims use the “1500 Health Insurance Claim Form” for paper
submissions, or HIPAA electronic equivalent. Information on the 1500 Health
Insurance Claim Form, including completion instructions, are published by an
agency of the American Medical Association and can be found on-line at: www.
nucc.org. The ADA recommends contacting your practice management system
vendor for information and assistance on submission of electronic medical claims.

5. What codes do I use when filing a claim against my patient’s medical


benefit plan?
Medical claims use procedure codes from the Current Procedure Terminology
(CPT) procedure code set maintained by the American Medical Association and
the Healthcare Common Procedure Code Set (HCPCS) maintained by the US
government. Medical claims also use a diagnosis code set (ICD-9-CM) that
is maintained by the US government. Various dental to medical cross-coding
references are available in print and online.
The ADA’s “CDT Companion” contains an extensive set of dental to medical
cross coding tables, addressing both procedure codes and diagnosis codes
(www.adacatalog.org / 800-947-4746).
Sources for procedure codes include, but are not limited to:
a. National Dental Advisory Service – www.ndas.com OR 800-669-3337
b. Webb Dental – www.webbdental.com OR 877-628-3366
Sources for ICD-9-CM codes include, but are not limited to:
a. icd9cm.chrisendres.com/
b. www.icd9coding.com
c. www.icd9data.com/
d. Medical Coding Books – www.medicalcodingbooks.com/icd9cm
OR 866-900-8300
Once you get to the ICD-9-CM code set you must go to the section on
diseases of the oral cavity, salivary glands and jaws (520-529) to find applicable
codes. There are other sections of ICD-9-CM that have codes that may be applicable
to a claim for dental services – Injuries (800 series); Accidents (E series)

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100+ Questions and Answers on the Code, Claim Formand Adjudication


Area of the Oral Cavity

6. In the past, our office has always used UR, UL, LR, and LL to indicate the
area of the oral cavity. I have heard that these symbols are not being used
any longer. Is this correct?
Yes, the Area of the Oral Cavity is now designated by a two-digit numeric code,
which is a HIPAA standard. This code is placed in Item 25 of the current ADA
paper claim form (2006 © American Dental Association). Completion instructions
for this field, as published in the CDT manual, follow:
25. Area of Oral Cavity: Use of this field is conditional. Always report the
area of the oral cavity unless one of the following conditions in Item #29
(Procedure Code) exists:
• The procedure identified in #29 requires the identification of a tooth
or a range of teeth.
• The procedure identified in #29 incorporates a specific area of the oral
cavity in its nomenclature (for example, D5110 complete denture –
maxillary).
• The procedure identified in #29 does not relate to any portion of the
oral cavity (for example, D5914 auricular prosthesis, or D9220 deep
sedation/general anesthesia – first 30 minutes).
Area of the oral cavity is designated by a two-digit code, selected from the
following code list:

Code Area
00 entire oral cavity
01 maxillary arch
02 mandibular arch
10 upper right quadrant
20 upper left quadrant
30 lower left quadrant
40 lower right quadrant

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7. The Universal/National Tooth Numbering System adopted by the ADA has a


way to enumerate supernumerary teeth. However, the ANSI/ADA/ISO tooth
numbering system also described in the CDT manual does not provide a way
to enumerate supernumeraries. Since both systems are recognized by the
ADA, why is there an inconsistency?
The Universal/National system, widely used within the United States, does
include a schema for supernumerary tooth identification. This schema
intentionally uses a two character code, the same maximum number of
characters used for identifying primary or permanent teeth (e.g., 1-32).
A two character format was selected as it would not require system
architecture changes to dentist practice management systems or payer claim
adjudication systems. The ADA House of Delegates has authority to amend
the Universal/National system.
The ANSI/ADA/ISO tooth enumeration system that is also described in the
CDT manual does not incorporate a means to identify supernumerary teeth.
A work request, initiated by the American Dental Association, has been
submitted to the International Standards Organization (ISO), the body that
maintains that enumeration system. Amending the ISO schema to identify
supernumerary teeth identification is being addressed by that standards
organization.

8. How do I enumerate supernumerary teeth?


Supernumerary teeth positions are identified by their relationship to adjacent
primary or permanent dentition. The dentist’s clinical observation and
decision determines the number assigned to supernumerary dentition. A single
supernumerary tooth in proximity to #22 would be numbered 72. If there is more
than one supernumerary tooth in the same location (e.g., 2 supernumerary teeth
are located distal to #1) each may be designated by the same number (e.g.,
51) with a note attached to the claim form submitted describing the multiple
supernumeraries present.

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100+ Questions and Answers on the Code, Claim Formand Adjudication


Adjudication Questions & Answers

Exclusions / Limitations

1. A patient is missing teeth 4,5,12 and 14. The dentist’s treatment plan
includes a bilateral removable partial denture. The insurance company denied
the partial because the teeth were extracted prior to the effective date of
the insurance policy. I don’t understand why the partial was denied.
Some group health plans restrict coverage for dental conditions present before
an individual’s enrollment in the plan, such as missing teeth. These restrictions
are known as “pre-existing conditions” exclusions.
Pre-existing condition exclusion may also be called a “waiting period” and
the length of time before coverage is available is specified in the benefit plan
documents. Times can vary and the patient should contact their employer or
insurance carrier for more information.
Please remember – dental benefit plan coverage limitation & exclusions, and
where applicable the provisions of a participating provider agreement, affect
third-party claim adjudication.

2. Dental benefit plan coverage limitation & exclusions, and where applicable
the provisions of a participating provider agreement, affect third-party
claim adjudication. Sometimes how a payer adjudicates a claim appears
inconsistent with the ADA’s message – “code for what you do.”
Example #1:
 The dentist reports “D2391 resin-based composite – one surface, posterior”
on tooth #18. A payer may adjudicate the claim using “D2140 amalgam –
one surface, primary or permanent” when the benefit contract makes an
allowance equivalent to an amalgam restoration on posterior teeth.
If this happens the Explanation of Benefits (EOB) should clearly give the
reasons for the action and not state or imply that the dentist filed the claim
incorrectly.
Please remember – dental benefit plan coverage limitation & exclusions, and
where applicable the provisions of a participating provider agreement, affect
third-party claim adjudication.

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Example #2:
A patient is missing teeth 3,4,12 and 13. The dentist’s treatment plan
includes two- four unit fixed partial dentures. When the claim is adjudicated,
the benefit contract makes an allowance equivalent to a removable bilateral
partial denture. This is an example of a benefit contract containing a least
expensive alternative treatment (LEAT) clause.
LEAT is a contractual limitation that will only allow benefits for the least
expensive treatment when there are multiple treatment options for a specific
condition. LEAT does not determine treatment, but does determine level of
benefits available.
Again, if this happens the Explanation of Benefits (EOB) should clearly give
the reasons for the action and not state or imply that the dentist filed the
claim incorrectly.
Please remember – dental benefit plan coverage limitation & exclusions, and
where applicable the provisions of a participating provider agreement, affect
third-party claim adjudication.

3. How do I know when a third-party payer is adjudicating a claim in accordance


with the benefit plan’s least expensive alternative treatment (LEAT) clause,
and when the claim is being downcoded during the adjudication process?
For example, I am a non-participating provider and submitted a claim for “D7240
removal of impacted tooth – completely bony.” When I received payment the
payer’s EOB stated that D7240 was changed to “D7230 removal of impacted
tooth – partially bony.” The EOB included a notation that D7230 is the
appropriate procedure code for the service provided and the amount paid was
calculated using fees for this lower cost procedure.
ADA policy adopted by the House of Delegates defines downcoding as “A practice
of third-party payers in which the benefit code has been changed to a less complex
and/or lower cost procedure than was reported, except where delineated in contract
agreements.” Your example is an illustration of downcoding because: 1) the third-
party payer unilaterally changed D7240 to the lower fee D7230; and 2) you have
not entered into a participating provider contract that could allow such an action.
This is not an example of applying a LEAT clause because the payer changed
the procedure code reported without any contractual justification.
Third-party payer actions like this, which are improper and misleading, should be
brought to the attention of ADA by contacting the Member Service Center.

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