WATCH

1. If full mouth debridement (D4355) is necessary to enable a comprehensive periodontal evaluation, either the prophy (D1110), or scaling and root planing (SRP), whichever is applicable, should follow on a separate service date. See D4355 for details.

2. If the patient requires both an adult prophylaxis (D1110) as well as a few teeth scaled and root planed (D4342), consider providing the adult prophylaxis at the first visit, and then provide the D4342 on a subsequent visit (some payors may require 6 weeks later). Prophylaxis does not preclude subsequent SRP. 

3. D4346 scaling in presence of generalized moderate or severe gingival inflammation - full mouth after the completion of an oral evaluation is used to report scaling performed on the patient with a documented diagnosis of generalized (>30%) moderate to severe gingival inflammation with no attachment loss. Pseudo pocketing may or may not be present. This is NOT a "difficult" prophy. See D4346 for details.

4. D1110 may be reported for patients with localized and/or mild gingivitis defined as not more than 30%. D1110 is not to be reported with D4346 on the same date of service; however, the D1110 procedure follows D4346 at a subsequent visit several weeks later, as determined by the dentist based on the individual patient's need. See D4346 for details.

5. A prophylaxis is a preventive and supportive procedure and is NOT a statement of health. It is not therapeutic or for the treatment of disease itself, but can be performed in addition to other therapeutic procedures.

COMMENTS

1. D1110 includes prophylaxis of implant crowns in conjunction with the permanent and transitional dentition. 

2. The D1110 descriptor includes the statement to "control local irritational factors." This procedure is to treat gingival inflammation (localized and mild gingivitis defined as less than 30% ) caused by irritational factors. If the tissue only has some mild or localized gingivitis with no bone loss, D1110 is indicated. Gingivitis is the first stage of periodontal disease and may, or may not, progress to periodontitis. If there is generalized (>30% ) moderate or severe gingival inflammation with no bone loss report D4346 instead of D1110. D4346 is NOT a "difficult" prophy. A "difficult" prophy is a prophylaxis requiring more time and effort. See comment #6 regarding a "difficult" prophy. See D4346 for details.

3. Adult prophylaxis (D1110) is preventive in nature and includes scaling and polishing of tooth structures (and implants) with the removal of plaque, calculus and stains. The removal of all calculus and plaque above and just below the CEJ is part of a prophylaxis. "Pseudo" pockets may be present, but there should not be bone loss or loss of attachment. If radiographic bone loss is evident and the root has access, see scaling and root planing (D4341/D4342). Instrumentation of the root with SRP is only possible when there is bone loss. 

4. Do not report prophylaxis (D1110) for the cleaning and inspection of partial and complete dentures. See D9932, D9933, D9934, and D9935. However, D1110 CAN be reported along with these procedures if cleaning natural teeth or implants on the same date of service. Benefits will vary by plan. See also point 6 under Limitations for more information.

5. A prophylaxis performed on a child having lost all his/her deciduous teeth (with only permanant teeeth) must be reported as adult prophylaxis (D1110), regardless of age. The D1110 fee for a child who has no "baby teeth" may be adjusted to the lower child prophylaxis fee if deemed appropriate by the dentist. If under age 14 include "permanent dentition only" in the remarks section and indicate the age.

6. Adult prophylaxis (D1110) does not include the application of topical fluoride. Report adult (or child) fluoride treatments, when applied separately from the prophylaxis paste, reporting either code D1208 or D1206. D1206 specifically requires the topical application of fluoride varnish. D1208 would include the topical application of any prescription strength fluoride product, excluding varnish (swish, trays, isolate, and paint- on). The application of fluoride must be applied separately from the prophylaxis paste. See D1206 and D1208 for additional information and how to increase the odds of adult fluoride reimbursement.

7. A “difficult” prophy may be a patient who presents with heavy plaque, calculus, staining, etc. requiring more time and challenging to perform, or even several visits. A “difficult” prophylaxis is accurately reported as a D1110 prophylaxis, regardless of the difficulty and/or he time needed to complete the procedure. The fee may be increased for the extra time spent, but maximum plan allowance will still apply. If greater than 30% of the mouth has inflammation, consider reporting D4346 instead. See D4346. 

LIMITATIONS

1. Adult prophylaxis (D1110) includes both transitional (mixed) and permanent dentition, and implants. Transitional dentition refers to a mixed dentition. Transitional dentition begins with the appearance of the permanent tooth and ends with the exfoliation (loss) of the last deciduous tooth. Permanent dentition refers to the permanent or adult teeth solely in the dental arch. Accordingly, any transitional dentition may be reported as an adult prophylaxis (D1110) regardless of age. However, many payors will apply an arbitrary age limitation (typically at least fourteen years of age) before considering reimbursement at the adult prophylaxis fee level.

2. The ADA's House of Delegates has, in the past, addressed the "age issue" and has passed a resolution that addresses this issue:
Age of "Child" (1991:635)
Resolved, that when dental plans differentiate coverage based on the child or adult status of the patient, this determination should be based on clinical development of the patient's dentition, and be it further resolved, that where administrative constraints of a dental plan preclude the use of clinical development so that chronological age must be used to determine child or adult status, the plan defines a patient as an adult beginning at age 12 with the exclusion of treatment for orthodontics and sealants.

3. Adult prophylaxis (D1110) is not reimbursed when provided on the same service date with ongoing periodontal maintenance (D4910) or full mouth debridement (D4355).

4. Adult prophylaxis (D1110) is typically reimbursed either on a "one per six months" (to the day!) or on a "two per year" basis. Under a few plans, only one prophylaxis per year is benefitted. Please note that other exceptions can apply to the reimbursement of D1110.
5. See periodontal scaling and root planing - one to three teeth per quadrant (D4342) regarding the reporting of prophylaxis (D1110) and SRP (D4342) on the same service date. This is generally a problem, and often requires an appeal indicating extra time was spent. It is not recommended.

6. If the patient has implant/abutment supported restorations only (no natural teeth remaining), D1110 may still apply since the code language includes implants in the descriptor. If denied by payors, report D1999 unspecified preventive service, by report and ask for the alternate benefit of D1110. Results will vary by plan. The exception would be in the case of fixed hybrid restorations, with which implant maintenance procedures would be appropriate. See D6080/D6180 for more information.

TIPS 

1. An adult prophylaxis (D1110) provided for a patient with transitional (mixed) dentition may be reported no matter the child's age, as long as there is at least one permanent tooth in the mouth. For example, an eleven-year-old boy with braces has "challenging" hygiene. In this scenario, the service may be reported as an adult prophylaxis (D1110); however, contract age limitations may be applied by payors. Alternately, the child prophy (D1120) may be reported in this situation and the fee adjusted accordingly. However, the plan limitations and reimbursement may vary widely from plan to plan.

2. The adult and child prophylaxis codes are dentition specific rather than age specific, and now include any implants or implant crowns. The payor reimbursement, however, is subject to contractual limitations.

NARRATIVES

1. Reimbursement for adult prophylaxis (D1110) is typically age specific and is determined by the terms of the insurance plan (plan document). Most payors set the "adult" age threshold at "14 or above." Some will begin recognizing the patient as an adult at "12 or above." A few payors begin to reimburse an adult prophy for those patients "16" years of age and older. A narrative stating "permanent dentition only" may help with the reimbursement process for patients who do not fall within the recognized plan document "norms."

2. If the patient requires extra time because they are an orthodontic patient presenting with calculus, cements and bonding agents remaining after the removal of braces report prophylaxis (D1110/D1120), in addition to an unspecified orthodontic procedure (D8999), with a narrative. PPOs will not reimburse for D8999, but some will allow the dentist to charge the additional unspecified D8999 fee directly to the patient under these circumstances. Thus, the procedure is denied. Review the contract language and the Medicaid or PPO's Processing Policy Manual to gain understanding of the limitations/exclusions.

CLINICAL FLOWCHARTS

1. The flow chart below shows the typical one prophylaxis visit prior to establishing the subsequent recall prophylaxis



2. D4346 at the time of the comprehensive oral evaluation (D0150) may only be used to report a procedure for the patient with a documented diagnosis of moderate to severe gingival inflammation without attachment loss. The D1110 procedure may follow D4346 at an interval set by the dentist. See flow chart below for an illustration of proper coding protocol. See also D4346. 



Notes: 

a. If a comprehensive oral evaluation (D0150) can be performed, with light to heavy calculus and debris present and a documented diagnosis of moderate severe gingivitis without attachment loss, then D4346 may be the appropriate treatment for the first visit. D1110 prophylaxis may follow at the second visit, with the interval set by the  dentist (such as two weeks). 

b. If a comprehensive oral evaluation (D0150/D0180) is not possible due to excess calculus and debris, see full mouth debridement (D4355) which is performed to enable a subsequent comprehensive periodontal evaluation and diagnosis. See D4355 for details and flow diagram. 

c. Ideally, adult prophylaxis (D1110) should not follow periodontal scaling and root planing - one to three teeth (D4342). If the patient requires both prophylaxis and a few teeth scaled and root planed (D4342), then consider the adult prophylaxis (D1110)for the first visit and the D4342 at a subsequent visit (wait at least six weeks after prophylaxis).
    Note: Some payers will not reimburse D4910 within a 90-day period following 
D4341/D4342. See D4342 for further details and the flow chart below: 

3. The flow chart below shows the evaluation /prophylaxis visit followed by SRP (D4342). In this circumstance, it may be appropriate to report either a prophy (D1110) or periodontal maintenance (D4910) at recall. 



Notes: 

1. Following a single SRP (D4342) visit, if very limited periodontal pockets are involved, the doctor has the latitude to provide adult prophylaxis (D1110) for recall maintenance (should generally be more often than two per year). Be sure and document in the patient’s clinical notes the isolated root planning (by tooth) at the adult prophylaxis (D1110) appointment and keep the patient informed of the :limited” nature of the periodontal treatment. On the other hand, ongoing periodontal maintenance (D4910) will be appropriate. However, keep in mind that some payors will not recognize D4910 for reimbursement if less than two initial quadrants (D4341/D4342) were scaled and root planed (DRP). In many cases, a single D4342 quadrant does not qualify for recall perio maintenance (D4910), and at least two full quadrants of D4341 are required. See D4910 for further details. 

2. Adult prophylaxis (D1110) will typically have a “one per six months” or “two per year” benefit limitation. Most plans benefit two prophylaxis (D1110) and two periodontal maintenance (D4910). A few plans benefit two prophecies and four periodontal maintenance (D4910) per year. See D4910.

3. Be sure to read SRP 1-3 teeth (D4342) for additional details and how this periodontal procedure relates to the adult prophylaxis (D1110) as to timing.