May 2019 Volume LIV Number 3

 
 
 
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Prophylaxis Billing for Children Under the Age of 14

May 2013 Volume XLVIX Number 3

Your office may want to notify your patients and parents of insurance contract provisions that reimburse for a child prophy rather than an adult prophy because of the age of the child, not the number of teeth the child has. Here is a sample notification.

 

Your childs current dentition (teeth erupted in the mouth at this time) does not qualify for the procedure code that we have used in the past (D1110). We are mandated by the federal government (under HIPAA) to submit current procedure codes as developed by the American Dental Association (ADA). The definitions of prophylaxis procedures are based on the dentition of the child, not the age of the child. Unfortunately, some dental benefit plans have contract limitations that conflict with the federal mandate and limit prophylaxis benefits based on the patients age.


The current ADA procedure code definitions are as follows:

 

Prophylaxis Adult (D1110)

 

Removal of plaque, calculus and stains from the tooth structures in the permanent and transitional dentition. It is intended to control local irritational factors.

 

Prophylaxis Child (D1120)

 

Removal of plaque, calculus and stains from the tooth structures in the primary and transitional dentition. It is intended to control local irritational factors.

 

Transitional dentition involves a mix of primary teeth and permanent teeth. This period typically begins with the appearance of the permanent first molars (around age 6) and ends with the exfoliation (falling out) of the last primary tooth (around ages 12-14). Since children lose teeth at different rates, the time period for this transition can vary. Determination of whether your child is a "transitional" adult or child will depend on the health of the mouth and the amount of time necessary to perform the procedure, work with the child (and parent) demonstrating and practicing tooth brushing, flossing, etc., and answering any questions either may have. Although dental benefit carriers are aware of these definitions, some have adopted payment limitations based on age rather than dentition to simplify claims administration.

 

When we submit your claim, we will send the following notice in order to help expedite the benefits from your carrier:

 

CDT 2013 states that an adult prophylaxis involves permanent and transitional dentition. A child prophylaxis involves primary and transitional dentition. This patient has full permanent dentition. If benefits are not available for prophylaxis-adult (D1110) due to contractual limitations, please consider an alternate benefit of prophylaxis-child (D1120).

 

In the event your dental benefit plan will not pay the benefits you are used to receiving, you may be responsible for the balance. We will do everything in our power to assist you in processing this claim. However, we cannot an adult prophylaxis as a child prophylaxis in order to satisfy age limit constraints of a dental plan. This could put our practice in legal jeopardy and in a position of willfully committing insurance fraud. Your understanding of this situation is greatly appreciated.