Adult Prophy vs. Child Prophy
There is often confusion over what defines an adult prophy and a child prophy. Most of us know dental plans are age-based from a reimbursement perspective. However, age does not determine how a prophy is reported. For several years, requests have been made and considered by the Code Maintenance Committee(CMC) to revise prophy codes to reflect age, but these requests have been rejected.
Coding guidelines state that the procedure code selected is the code that most accurately describes and represents the procedure performed. Select the code from the current CDT code set. Remember, CDT codes are reviewed and updated on an annual basis, and any changes become effective for dates of service beginning on January 1 of each year.
A CDT code is five-digits consisting of alpha and numeric characters. The first digit is the letter D, followed by four numbers. Following the code number is the nomenclature, which is a title that defines what the code is. Some codes also include a descriptor below the nomenclature, which further clarifies and explains the proper utilization of the code. We, as dental team members, often overlook reading the full nomenclature and descriptor. A review of the complete code language for prophy – adult and child will provide clarity on the proper use of these codes. Remember, the purpose of CDT codes is for documentation and reporting purposes. Therefore, use the code appropriately whether the patient is insured or not.
D1110 prophylaxis – adult
Removal of plaque, calculus and stains from the tooth structures in the permanent and transitional dentition. It is intended to control local irritational factors
D1120 prophylaxis – child
Removal of plaque, calculus and stains from the tooth structures in the primary and transitional dentition. It is intended to control local irritational factors
The descriptor for D1110 and D1120, indicating the patient’s current dentition, is how the proper code is selected, not the age of the patient.
Code D1120 would accurately report a prophy performed on a patient with all primary dentition or one with primary and permanent dentition.
Code D1110 would accurately report a prophy performed on a patient with all permanent dentition.
The next scenario is where choosing the appropriate code gets a little tricky. Code D1120 or D1110 may report a prophy performed on a patient with transitional dentition (a mix of primary and permanent). For instance, a child with horrendous homecare with transitional dentition can be reported with D1110.
What is not appropriate is reporting D1120 for a child with full permanent dentition, regardless of the age limitation of the dental plan. It is not unusual for an 11-year-old child to present with full permanent (adult) dentition; therefore, D1110 prophylaxis – adult would be appropriate for this 11-year-old child example.
Do not rely entirely on the descriptions of CDT codes entered in our software as we are limited to the number of characters that may be entered and often abbreviated. Review CDT code changes annually to ensure proper utilization of codes. Remember, the addition or deletion of just one word from a code nomenclature or descriptor can completely change the usage of a code. Report what you do, regardless of how any dental benefits are considered for reimbursement. All dental plans contain limitations and exclusions, such as age limitations. Plan limitations only determine how and when reimbursement is made, not how the code is reported. Code language does not change based on any plan limitations.
Author: Dilaine Gloege, CDA, CPC