AETNA RESERVES THE RIGHT TO CHANGE OR UPDATE THIS

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CLAIM DOCUMENTATION GUIDELINES
Current CDT
CODE*
Restorative
D2390
D2542-D2544
D2642-D2644
D2662-D2664
D2710-D2799
D2929-D2930
D2960-D2962
D2950
D2971
Endodontics
D3331
DOCUMENTATION GUIDELINES
Current dated pre-operative radiographs ■
Prior placem ent date and rationale for replacem ent, if applicable
Pre-operative and post-operative photos
Current dated pre-operative radiographs ■
Narrative▲
D3428-D3429
Current dated pre-operative radiographs and post-operative radiographs ■
Narrative▲
Current dated pre-operative radiographs ■
D3431-D3432
Current dated pre-operative radiographs ■
Periodontal
D4245
Based on the Am erican National Standard/Am erican Dental Association Specification No. 1047,
Standard Content of an Electronic Periodontal Attachm ent
Current dated pre-operative periodontal charting ●
Narrative▲
Current dated pre-operative periodontal charting ●
Current dated pre-operative radiographs ■
Current dated pre-operative periodontal charting ●
D4249
Current dated pre-operative radiographs ■
D4260 & D4261
Current dated pre-operative
Current dated pre-operative
Current dated pre-operative
Identify each site
Current dated pre-operative
D4210 & D4211
D4212
D4240 & D4241
D4263, D4264,
D4266, D4267
D4265
D4268
D4270, D4273,
D4275, D4276,
D4277, D4278,
D4283 & D4285
periodontal charting ●
radiographs ■
periodontal charting ●
radiographs ■
Note: A single code for m ultiple sites is not valid.
Narrative▲
Material Used
Current dated pre-operative radiographs ■
Narrative w ith tooth/teeth num bers and rationale for surgical revision▲
Note: Date of surgical revision should be no m ore than tw enty-four m onths and generally no
less than six m onths from the date of the initial surgery.
For each tooth/site proposed to receive a soft tissue graft, A chart or narrative containing the
follow ing Mucogingival Data
•
Tooth # _____
•
MM Recession_______
•
MM Attached Gingiva ______
•
MM Attached Keratinized Gingiva _______
AETNA RESERVES THE RIGHT TO CHANGE OR UPDATE THIS INFORMATION WITHOUT NOTICE CDT
2017
*
©
Current Dental Terminology. American Dental Association. All rights reserved.
Last updated 08/22/2016
CLAIM DOCUMENTATION GUIDELINES
D4274
D4320 & D4321
D4341 & D4342
D4346
D4381
Prostheses
D5875
Im plant Services
D6010-D6050,
D6104
D6052-D6079
D6094 & D6194
D6110-D6117
Current dated pre-operative periodontal charting ●
Current dated pre-operative radiographs ■
Current dated pre-operative radiographs ■
Current dated pre-operative periodontal charting ●
Prior periodontal treatm ent history
Teeth num bers being treated
Current dated pre-operative periodontal charting ●
Current dated pre-operative radiographs ■
Current dated pre-operative periodontal charting ●
Current dated pre-operative radiographs or photographs ■
Current dated pre-operative periodontal charting ●
Narrative▲
Current dated full m outh pre-operative radiographs and/or panoram ic radiograph ■
Extraction dates of teeth to be replaced
Date of prior prosthetic placem ent (fixed and/or rem ovable dentures, if applicable)
Num bers of all m issing teeth
Tooth num ber of proposed im plants
Current dated full m outh pre-operative radiographs and/or panoram ic radiograph ■
Extraction dates of teeth to be replaced
Date of prior prosthetic placem ent (fixed and/or rem ovable dentures, if applicable)
Num bers of all m issing teeth
Tooth num ber (s) of proposed treatm ent sites (s)
•
The radiographs should be post-operative to the im plant placem ent, but pre-operative to
the
crow n and /or bridge placem ent.
Current Post-Operative Radiograph ■
Narrative▲
Date of prior im plant placem ent
D6081
D6090, D6091,
D6093, D6095,
D6100
D6101, D6102,
Current dated full m outh pre-operative radiographs and/or panoram ic radiograph ■
D6103
Prosthodontics, fixed
D6205-D6252
Current dated full m outh pre-operative radiographs and/or panoram ic radiograph ■
D6545 D6549
Extraction dates of teeth to be replaced
D6600-D6634
Date of prior prosthetic placem ent (fixed and/or rem ovable dentures, and rationale), and
D6710-D6794
rationale for replacem ent if applicable
D6985
Num bers of all m issing teeth
Oral And Maxillofacial Surgery
D7210-D7240,
Current dated full m outh pre-operative radiographs and/or panoram ic radiograph ■
All 3rd m olar extractions on patients age 15 or under to include rationale for extraction
D7241
Current dated full m outh pre-operative radiographs and/or panoram ic radiograph ■
Narrative▲ – All D7241 to include rationale for unusual surgical com plications
D7251
Current dated full m outh pre-operative radiographs and/or panoram ic radiograph
Narrative▲ –to include rationale for unusual surgical com plications
D7410- D7415,
Pathology report
D7465
D7450-D7461
Current dated pre-operative radiographs ■
Pathology report
AETNA RESERVES THE RIGHT TO CHANGE OR UPDATE THIS INFORMATION WITHOUT NOTICE CDT
2017
*
©
Current Dental Terminology. American Dental Association. All rights reserved.
Last updated 08/22/2016
CLAIM DOCUMENTATION GUIDELINES
D7950-D7953
Current dated full m outh pre-operative radiographs and/or panoram ic radiograph ■
Narrative describing the planned prosthetic reconstruction ▲
Num ber of m issing tooth or area
Adjunctive
D9220-D9248
Current dated pre-operative radiographs ■
Narrative▲
Anesthesia Records
D9952
Current dated pre-operative radiographs ■
Narrative▲
By Report" procedures
D2999 D3999
Narrative describing specific clinical conditions addressed by the procedure, rationale
D4999 D5899
dem onstrating need, pertinent history and treatm ent plan ▲
Radiographs, if applicable, to assist in describing clinical condition ■
D5999 D6199
D6999 D7999
D8999 D9999
General Com m ents
■
QUALITY OF RADIOGRAPHS: All radiographic images should be of diagnostic quality, depicting appropriate
structures, dated, mounted, and labeled right and left. Submitted radiographs should be duplicates and less
than 36 months old and labeled w ith the patient’s name and the provider’s name and address. DO NOT SEND
ORIGINAL RADIOGRAPHS SINCE THEY WILL NOT BE RETURNED. ELECTRONIC IMAGES OF THE
RADIOGRAPHS WILL BE RETAINED BY AETNA.
●
▲
PERIODONTAL CHARTING: Must be com prehensive full m outh, legible, dated, docum ented w ith
probing depths (up to six per tooth), recorded in m m . per tooth, labeled right and left,
m andibular and m axillary, w ith classified furcation defects and tooth m obility recorded as 1st, 2nd
or 3rd degree.
WRITTEN NARRATIVES: Must be clear, legible and provide rationale for the proposed treatm ent.
Exam ple: describes specific clinical conditions addressed by the procedure.
These guidelines represent frequently subm itted procedures w hich require attachm ents and
are not all inclusive. There m ay be other dental procedures not listed w hich require additional
docum entation. Subm it only a com pleted claim for routine dental procedures such as
cleanings and m inor restorations, unless otherw ise requested.
AETNA RESERVES THE RIGHT TO CHANGE OR UPDATE THIS INFORMATION WITHOUT NOTICE CDT
2017
*
©
Current Dental Terminology. American Dental Association. All rights reserved.
Last updated 08/22/2016
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