Insurance Coding for Pediatric Care
It is recommended that all children see a dentist by the age of one or by the eruption of their first tooth, whichever comes first. The following guidelines will help you bill for the services correctly.
Some insurance carriers may:
- Place frequency limits on certain services.
- Reimburse code DO145 explicitly if any other comprehensive exam codes (D0150, D0160, or D0180) are submitted for children under age 3.
- Pay subsequent D0145 submissions as D0120.
- Require subsequent follow-up visits for children under age three to be charged with the D0120 code instead of the D0145 code.
- Consider individually listed intraoral radiographs by the same dentist/office a complete series if the fee for individual radiographs equals or exceeds the cost for a complete series done on the same date of service.
D0145 Oral evaluation for a patient under three years of age and counseling with the primary caregiver
Diagnostic services performed for a child under the age of three, preferably within the first six months of the eruption of the first primary tooth, including recording the oral and physical health history, evaluation of caries susceptibility, development of an appropriate preventive oral health regimen, and communication with and counseling of the child’s parent, legal guardian and/or primary caregiver.
D0120 Periodic oral evaluation—established patient
An evaluation is performed on a patient’s record to determine any changes in the patient’s dental and medical health status since a previous comprehensive or periodic evaluation. This includes an oral cancer evaluation and periodontal screening where indicated, and may require interpretation of information acquired through additional diagnostic procedures. Report additional diagnostic procedures separately.
D0220 Intraoral—periapical first radiographic image
Intraoral—occlusal radiographic image. Image capture with interpretation.
D0230 Intraoral—periapical, each additional radiographic image
Intraoral—occlusal radiographic image. Image capture with interpretation
D0240 Intraoral—occlusal radiographic image
Intraoral – occlusal radiographic image. Image capture with interpretation
DO272 Bitewings—two radiographic images
Age Limit: 0-13
Teeth: N/A
Prior Authorization Required: No
Benefit Limitation: Two of (D110, D1120) per 12 months per patient. Includes minor scaling procedures.
Age Limit: 0-20
Teeth: N/A
Prior Authorization Required: No
Benefit Limitation: One of (D1206, D1208) per 1 day per patient per provider or location. Cannot be billed with D1208 or the same date of service by the same provider or location.
Age Limit: 0-20
Teeth: N/A
Prior Authorization Required: No
Benefit Limitation: One of D1208 or D1206 per 1 day per patient (provide or location). Cannot be billed with D1206 on the same date of service by the same provider or at the same location.
Age Limits: 0 -3
Teeth: N/A
Prior Authorization Required: No
Benefit of Limitation: Two of (D0120, DO145) per 12 months per patient per (provider or location). Twice per calendar year.
Description: Diagnostic services performed for a child under the age of three, preferably within the first six months of the eruption of the first primary tooth, including recording the oral and physical health history, evaluation of caries susceptibility, development of an appropriate preventive oral health regimen, and communication with and counseling of the child’s parent, legal guardian and/or primary caregiver.