Billing Guide for D1351 (Sealant Per Tooth)
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Description
Billing Guidelines, Tips and Reminders for D1351 (Sealant Per Tooth)
February 03, 2025
COMMENTS
The differences between a sealant (D1351), preventive resin restoration (D1352), and resin-based composite restoration (D2391) are:
1. Sealant (D1351): Mechanically and/or chemically prepared enamel surface sealed to prevent decay. The enamel surface is non-carious. The global fee for a sealant includes a fissurotomy, as a part of the procedure, if it is necessary.
2. Preventive Resin Restoration (D1352): Conservative restoration of an active cavitated lesion in a pit or fissure of a permanent tooth which does not extend into the dentin; also includes placing a sealant in any of the radiating non-carious fissures or pits. Patient must be moderate to high caries risk. D1352 can only be reported for permanent teeth.
3. Resin-based composite-One surface, posterior (D2391): This is a resin composite restoration where the caries and preparation extends into the dentin or a deeply eroded area into the dentin.
4. Enter the tooth number being sealed in Box 27 of the 2024 ADA Dental Claim Form.
LIMITATIONS
1. Reimbursement of sealants is generally limited to the occlusal surface of the permanent first and second molars. Some plans will provide reimbursement for sealants provided for permanent premolars; however, this is quite rare. There may be exclusions for sealants if the tooth has been previously restored with an occlusal restoration or if caries is present. Sealants are reported on a "per tooth" basis.
2. The sealant replacement exclusion varies from two to five years or to the lifetime of the insured. For sealant repair, per tooth, see D1353.
3. Sealant coverage for permanent molars varies, and may cover the period from eruption to 15 or 18 years of age. Some plans cover first molars only from age 6-10. Most payors have an age limit. The reimbursement for sealants is highly variable. It is recommended that sealant coverage be verified prior to placement.
4. Sealants typically are reimbursed as a preventive procedure. Most plans cover preventive procedures at 100% of the payor's allowance. Other payors consider sealants a basic service and some consider sealants under the "major" category of benefits. If considered a basic or major benefit, the reimbursement will be less than a 100% payor's fee, per the plan's benefit structure. There may be waiting periods, co-payments, deductibles, or other limitations that apply to sealant services. The reimbursement for sealants is highly variable.
5. If amalgams/composites are performed along with sealants on the same tooth, on the same service, then the sealants are usually considered a part of the global amalgam/composite procedure.
6. Sealants may be applied to primary teeth but typical are not reimbursed.
7. Sealants are not generally covered for adults, but may be beneficial.
8. Enter the tooth number being sealed in Box 27 of the 2024 ADA Dental Claim Form.
TIPS
See also D2990 resin infiltration of incipient smooth surface lesions (DMG Icon) and D2991 application of hydroxyapatite regeneration medicament (Curodont Repair). These are both restorative codes, not preventive.
The differences between a sealant (D1351), preventive resin restoration (D1352), and resin-based composite restoration (D2391) are:
1. Sealant (D1351): Mechanically and/or chemically prepared enamel surface sealed to prevent decay. The enamel surface is non-carious. The global fee for a sealant includes a fissurotomy, as a part of the procedure, if it is necessary.
2. Preventive Resin Restoration (D1352): Conservative restoration of an active cavitated lesion in a pit or fissure of a permanent tooth which does not extend into the dentin; also includes placing a sealant in any of the radiating non-carious fissures or pits. Patient must be moderate to high caries risk. D1352 can only be reported for permanent teeth.
3. Resin-based composite-One surface, posterior (D2391): This is a resin composite restoration where the caries and preparation extends into the dentin or a deeply eroded area into the dentin.
4. Enter the tooth number being sealed in Box 27 of the 2024 ADA Dental Claim Form.
LIMITATIONS
1. Reimbursement of sealants is generally limited to the occlusal surface of the permanent first and second molars. Some plans will provide reimbursement for sealants provided for permanent premolars; however, this is quite rare. There may be exclusions for sealants if the tooth has been previously restored with an occlusal restoration or if caries is present. Sealants are reported on a "per tooth" basis.
2. The sealant replacement exclusion varies from two to five years or to the lifetime of the insured. For sealant repair, per tooth, see D1353.
3. Sealant coverage for permanent molars varies, and may cover the period from eruption to 15 or 18 years of age. Some plans cover first molars only from age 6-10. Most payors have an age limit. The reimbursement for sealants is highly variable. It is recommended that sealant coverage be verified prior to placement.
4. Sealants typically are reimbursed as a preventive procedure. Most plans cover preventive procedures at 100% of the payor's allowance. Other payors consider sealants a basic service and some consider sealants under the "major" category of benefits. If considered a basic or major benefit, the reimbursement will be less than a 100% payor's fee, per the plan's benefit structure. There may be waiting periods, co-payments, deductibles, or other limitations that apply to sealant services. The reimbursement for sealants is highly variable.
5. If amalgams/composites are performed along with sealants on the same tooth, on the same service, then the sealants are usually considered a part of the global amalgam/composite procedure.
6. Sealants may be applied to primary teeth but typical are not reimbursed.
7. Sealants are not generally covered for adults, but may be beneficial.
8. Enter the tooth number being sealed in Box 27 of the 2024 ADA Dental Claim Form.
TIPS
See also D2990 resin infiltration of incipient smooth surface lesions (DMG Icon) and D2991 application of hydroxyapatite regeneration medicament (Curodont Repair). These are both restorative codes, not preventive.
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