AETNA RESERVES THE RIGHT TO CHANGE OR UPDATE THIS

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CLAIM DOCUMENTATION GUIDELINES

DOCUMENTATION GUIDELINES Current CDT

CODE*

Restorative

D2390

D2542-D2544

D2642-D2644

D2662-D2664

D2710-D2799

D2929-D2930

D2960-D2962

D2950

D2971

Endodontics

D3331

D3428-D3429

D3431-D3432

Periodontal

D4210 & D4211

D4212

D4240 & D4241

D4245

D4249

D4260 & D4261

D4263, D4264,

D4266, D4267

D4265

D4268

D4270, D4273,

D4275, D4276,

D4277, D4278,

D4283 & D4285

Current dated pre-operative radiographs

Prior placem ent date and rationale for replacem ent, if applicable

Pre-operative and post-operative photos

Current dated preoperative radiographs ■

Narrative▲

Current dated pre-operative radiographs and post-operative radiographs

Narrative▲

Current dated pre-operative radiograp hs ■

Current dated preoperative radiographs ■

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 preoperative periodontal charting ●

Current dated pre-operative radiographs

Current dated preoperative periodontal charting ●

Current dated pre-operative radiographs

Current dated preoperative periodontal charting ●

Current dated pre-operative radiographs

Current dated preoperative periodontal charting ●

Identify each site

Current dated pre-operative 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.

Last updated 08/22/2016

©

American Dental Association. All rights reserved.

D4274

D4320 & D4321

D4341 & D4342

D4346

D4381

CLAIM DOCUMENTATION GUIDELINES

Current dated pre-operative periodontal charting

Current dated preoperative radiographs ■

Current dated preoperative 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 preoperative radiographs ■

Current dated pre-operative periodontal charting

Current dated pre-operative radiographs or photographs

Current dated pre-operative periodontal charting

Prostheses

D5875

Narrative▲

Im plant Services

D6010-D6050,

D6104

D6052-D6079

D6094 & D6194

D6110-D6117

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,

D6103

Current dated full m outh preoperative radiographs and/or panoramic radiograph ■

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

D6710-D6794

D6985

Date of prior prosthetic placem ent (fixed and/or rem ovable dentures, and rationale), and rationale for replacem ent if applicable

Num bers of all m issing teeth

Oral And Maxillofacial Surgery

D7210-D7240,

D7241

Current dated full m outh pre-operative radiographs and/or panoram ic radiograph

All 3 rd

m olar extractions on patients age 15 or under to include rationale for extraction

Current dated full m outh preoperative radiographs and/or panoramic radiograph ■

Narrative▲ – All D7241 to include rationale for unusual surgical complications

D7251

D7410- D7415,

Current dated full m outh pre-operative radiographs and/or panoram ic radiograph

Narrati ve▲ –to include rationale for unusual surgical complications

Pathology report

D7465

D7450-D7461 Current dated preoperative radiographs ■

Pathology report

AETNA RESERVES THE RIGHT TO CHANGE OR UPDATE THIS INFORMATION WITHOUT NOTICE CDT

2017

*

Current Dental Terminology.

Last updated 08/22/2016

©

American Dental Association. All rights reserved.

D7950-D7953

CLAIM DOCUMENTATION GUIDELINES

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

D9952

Current dated preoperative radiographs ■

Narrative▲

Anesthesia Records

Current dated preoperative radiographs ■

Narrat ive▲

By Report" procedures

D2999 D3999

D4999 D5899

D5999 D6199

D6999 D7999

D8999 D9999

Narrative describing specific clinical conditions addressed by the procedure, rationale dem onstrating need, pertinent history and treatm ent plan

Radiographs, if applicable, to assist in describing clinical condition

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 1 st

, 2 nd or 3 rd

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.

Last updated 08/22/2016

©

American Dental Association. All rights reserved.

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