January 2002: Dental Provisions #18
REQUIRED ATTACHMENT DOCUMENTATION
Diagnostic Procedures D0100-D0999
| CDT Procedure
Code |
Description |
Narrative/By
Report |
| D0160 |
Detailed and extensive oral evaluation |
X |
| D0170 |
Re-evaluation limited, problem focused |
X |
| D0310-D0322 |
TMD radiographs |
X |
| D0340 |
Cephalometric film |
X |
| D0501-D0502 |
Histopathologic exam/pathology procedures |
X |
| D0999 |
Unspecified diagnostic procedure |
X |
Restorative Procedures D2000-D2999
| CDT Procedure
Code |
Description |
X-ray
Date R&L |
Photo
(When Available) |
Age
of Existing Restoration |
Narrative/
By Report |
| D2510-D2664 |
Inlay/onlay restoration |
X |
X |
X |
X |
| D2710-D2799 |
Crown restoration |
X |
X |
X |
X |
| D2930-D2933 |
Stainless steel crown |
|
|
|
X (If done on permanent
tooth) |
| D2950-D2957 |
Buildups/posts |
X |
X |
X |
X |
| D2960-D2962 |
Veneer |
X |
X |
X |
X |
| D2970 |
Temporary crown |
X |
X |
X |
X |
| D2980 |
Crown repair |
|
|
|
X |
| D2999 |
Unspecified restorative procedure |
|
|
|
X |
Endodontic Procedures D3000-D3999
| CDT Procedure Code |
Description |
X-ray Date
R&L |
Date of Original
Root Canal |
Narrative/
By Report |
| D3331 |
Treatment of root canal obstruction |
X |
|
X |
| D3332 |
Incomplete endodontic therapy |
X |
|
X |
| D3333 |
Internal root repair of perforation
defects |
X |
X |
X |
| D3346-D3348 |
Retreatment of previous root canal
therapy |
X |
X |
X |
| D3460 |
Endodontic endosseous implant |
X |
|
X |
| D3470 |
Intentional reimplantation |
X |
|
X |
| D3999 |
Unspecified endodontic procedure |
|
|
X |
Periodontic Procedures D4000-D4999
| CDT Procedure Code |
Description |
X-ray Date R&L |
Pocket Charting |
Schematic Perio Charting |
Narrative/By Report |
| D4240 |
Gingival flap procedure |
|
X |
X |
XX |
| D4245 |
Apically positioned flap |
|
X |
X |
XX |
| D4249 |
Clinical crown lengthening |
X |
X |
|
XX |
| D4260 |
Osseous surgery |
X |
|
X |
XX |
| D4263 |
Bone replacement graft |
X |
|
X |
XX |
| D4264 |
Bone replacement graft |
X |
|
X |
XX |
| D4266 |
Guided tissue regeneration |
|
|
X |
XX |
| D4267 |
Guided tissue regeneration |
|
|
X |
XX |
| D4268 |
Surgical revision procedure |
X |
X |
|
XX |
| D4270 |
Pedicle soft tissue graft |
|
|
X |
XX |
| D4271 |
Free soft tissue graft |
|
|
X |
XX |
| D4273 |
Subepithelial connective tissue graft |
|
|
X |
XX |
| D4274 |
Distal or proximal wedge procedure |
|
|
|
X |
| D4320-D4321 |
Provisional splinting |
X |
X |
|
X |
| D4355 |
Full mouth debridement |
|
|
|
X |
| D4920 |
Unscheduled dressing change |
|
|
|
X |
| D4999 |
Unspecified periodontal procedure |
|
|
|
X |
Prosthodontic Procedures D5000-D6999
| CDT Procedure Code |
Description |
X-ray Date R&L |
Photo (When
Available) |
Age of Existing
Restoration |
Date of Extraction |
Narrative/
By Report |
| D5110-D5140 |
Complete dentures |
|
|
* |
* |
* |
| D5211-D5281 |
Partial dentures |
|
|
X |
X |
X |
| D5820-D5821 |
Interim partial denture |
|
|
X |
X |
X |
| D5860-D5861 |
Overdenture-complete/partial |
|
|
X |
X |
X |
| D5999 |
Unspecified maxillofacial prosthesis |
|
|
|
|
X |
| D6010-D6199 |
Implant procedures |
X |
|
X |
X |
X |
| D6210-D6252 |
Fixed partial denture pontics |
X |
|
X |
X |
X |
| D6519-D6548 |
Fixed partial denture-inlay/onlay |
X |
|
X |
X |
X |
| D6720-D6792 |
Fixed partial denture-crowns |
X |
|
X |
X |
X |
| D6999 |
Unspecified fixed prosthodontic procedure |
|
|
|
|
X |
Oral & Maxillofacial Surgery D7000-D7999
| CDT Procedure Code |
Description |
X-ray Date
R&L |
Narrative |
| D7230-D7250 |
Surgical removal of teeth or roots |
X |
X |
| D7260-D7999 |
Other surgical procedures |
X |
X |
| X = |
Narrative (report) required. |
| XX = |
Narrative necessary if conditions
exist that are not well-illustrated by the x-ray
or charting. |
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