Audience
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Policy No:  08

Originally Created: 03/01/1997

Section: Preventive

Last Reviewed:  01/01/2019

Last Revised:  01/01/2018

Approved: 01/01/2018

Effective:  01/01/2018

Description

Prophylaxis – adult (D1110)

A dental prophylaxis performed on transitional or permanent dentition which includes scaling and polishing procedures to remove coronal plaque, calculus and stains. Some patients may require more than one appointment or one extended appointment to complete a prophylaxis.

Prophylaxis – child (D1120)

Refers to a dental prophylaxis performed on primary or transitional dentition only.

Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation (D4346):

Should not be reported in conjunction with prophylaxis, scaling and root planning or debridement procedures.

Policy/criteria

Procedures are in accordance with generally accepted standards of dental practice.

Billing for an adult verses a child prophylaxis is determined by the dentist based on the dentition of the patient.

Administrative guidelines

Process to contract benefits.

If the dentist reports two routine dental prophylaxis on the same claim and indicates the treatment required more than one visit to complete, process each routine prophylaxis separately.

Codes

CDT - D1000-D1999 - see above

Disclaimer

Your use of this Dental Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Dental Policy Disclaimer.