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.