Help

SELECTHEALTH 2018 DENTAL CODE REQUIREMENTS


CODE DESCRIPTION INFORMATION NEEDED
D0999 Unspecified diagnostic procedure, by report NARRATIVE
D1520 Space maintainer – removable – unilateral NARRATIVE
D1525 Space maintainer – removable – bilateral NARRATIVE
D1999 Unspecified preventive procedure, by report NARRATIVE
D2335 Resin-based composite – four or more surfaces or involving incisal angle (anterior) X–RAYS
D2390*  Resin–based composite crown, anterior X–RAYS
D2520 Inlay – metallic – two surfaces X-RAY AND/OR NARRATIVE
D2530 Inlay – metallic – three or more surfaces X-RAY AND/OR NARRATIVE
D2542 Onlay – metallic – two surfaces X-RAY AND/OR NARRATIVE
D2543 Onlay – metallic – three surfaces X-RAY AND/OR NARRATIVE
D2544 Onlay – metallic – four or more surfaces X-RAY AND/OR NARRATIVE
D2610 Inlay – porcelain/ceramic – one surface X-RAY AND/OR NARRATIVE
D2620 Inlay – porcelain/ceramic – two surfaces X-RAY AND/OR NARRATIVE
D2630 Inlay – porcelain/ceramic – three or more surfaces X-RAY AND/OR NARRATIVE
D2642 Onlay – porcelain/ceramic – two surfaces X-RAY AND/OR NARRATIVE
D2643 Onlay – porcelain/ceramic – three surfaces X-RAY AND/OR NARRATIVE
D2644 Onlay – porcelain/ceramic – four or more surfaces X-RAY AND/OR NARRATIVE
D2650 Inlay – resin-based composite – one surface  X-RAY AND/OR NARRATIVE
CODE DESCRIPTION INFORMATION NEEDED
D2651 Inlay – resin-based composite – two surfaces X-RAY AND/OR NARRATIVE
D2652 Inlay – resin-based composite – three or more surfaces X-RAY AND/OR NARRATIVE
D2662 Onlay – resin-based composite – two surfaces X-RAY AND/OR NARRATIVE
D2663 Onlay – resin-based composite – three surfaces X-RAY AND/OR NARRATIVE
D2664 Onlay – resin-based composite – four or more surfaces X-RAY AND/OR NARRATIVE
D2710* Crown – resin-based composite (indirect) X–RAYS
D2712* Crown – 3/4 resin–based composite (indirect) X–RAYS
D2720* Crown – resin with high noble metal X–RAYS
D2721* Crown – resin with predominantly base metal X–RAYS
D2722* Crown – resin with noble metal X–RAYS
D2740* Crown – porcelain/ceramic substrate X–RAYS
D2750* Crown – porcelain fused to high noble metal X–RAYS
D2751* Crown – porcelain fused to predominantly base metal X–RAYS
D2752* Crown – porcelain fused to noble metal X–RAYS
D2780* Crown – 3/4 cast high noble metal X–RAYS
D2781* Crown – 3/4 cast predominantly base metal  X–RAYS
D2782* Crown – 3/4 cast noble metal X–RAYS
CODE DESCRIPTION INFORMATION NEEDED
D2783* Crown – 3/4 porcelain/ceramic (This code does not include facial veneers) X–RAYS
D2950 Core buildup, including any pins when required X–RAYS
D2960 Labial veneer (resin laminate) – chairside X–RAYS
D2961 Labial veneer (resin laminate) – laboratory X–RAYS
D2962 Labial veneer (porcelain laminate) – laboratory X-RAYS
D2971 Additional procedures to construct new crown under existing partial NARRATIVE
D2980 Crown repair necessitated by restorative material failure NARRATIVE
D2981 Inlay repair necessitated by restorative material failure NARRATIVE
D2982 Onlay repair necessitated by restorative material failure  NARRATIVE
D2983 Veneer repair necessitated by restorative material failure NARRATIVE
D2999 Unspecified restorative procedure, by report NARRATIVE 
D3331 Treatment of root canal obstruction, non–surgical access  NARRATIVE AND X–RAYS
D3431 Biologic materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery NARRATIVE STATING WHICH MATERIALS WERE USED
D3999 Unspecified endodontic procedure, by report NARRATIVE
D4210 Gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded  spaces per quadrant PERIO CHARTING
D4211 Gingivectomy or gingivoplasty – one to three contiguous teeth or tooth bounded spaces per quadrant PERIO CHARTING
CODE DESCRIPTION INFORMATION NEEDED
D4240 Gingival flap procedure, including root planing – four or more contiguous teeth or tooth bounded spaces per quadrant PERIO CHARTING
D4241 Gingival flap procedure, including root planing – one to three contiguous teeth or tooth bounded spaces per quadrant PERIO CHARTING
D4245 Apically positioned flap PERIO CHARTING
D4249 Clinical crown lengthening – hard tissue NARRATIVE AND X–RAYS
D4260 Osseous surgery (including elevation of a full thickness flap and closure)- four or more contiguous teeth or tooth bounded spaces per quadrant PERIO CHARTING
D4261 Osseous surgery (including elevation of a full thickness flap and closure)- one to three contiguous teeth or tooth bounded spaces per quadrant PERIO CHARTING
D4263 Bone replacement graft – retained natural tooth - first site in quadrant PERIO CHARTING
D4264 Bone replacement graft – retained natural tooth - each additional site in quadrant  PERIO CHARTING
D4265 Biologic materials to aid in soft and osseous tissue regeneration NARRATIVE STATING WHICH MATERIALS WERE USED
D4266 Guided tissue regeneration – resorbable barrier, per site PERIO CHARTING, NARRATIVE
D4267 Guided tissue regeneration – non-resorbable barrier, per site, (includes membrane removal) PERIO CHARTING, NARRATIVE
D4268 Surgical revision procedure, per tooth PERIO CHARTING, NARRATIVE
D4270 Pedicle soft tissue graft procedure PERIO CHARTING, NARRATIVE
CODE DESCRIPTION INFORMATION NEEDED
D4273 Autogenous connective tissue graft procedure (including donor and recipient surgical sites), first tooth, implant, or edentulous tooth position in graft PERIO CHARTING, NARRATIVE
D4274 Mesial/distal wedge procedure, single tooth (when not performed in conjunction with surgical procedures in the same anatomical area) PERIO CHARTING
D4275 Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentulous tooth position in graft PERIO CHARTING NARRATIVE
D4276 Combined connective tissue and double pedicle graft, per tooth PERIO CHARTING
NARRATIVE
D4283 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) – each additional contiguous tooth, implant or edentulous tooth position in same graft site PERIO CHARTING NARRATIVE
D4285 Non-autogenous connective tissue graft procedure (including recipient surgical site and donor material) – each additional contiguous tooth, implant or edentulous tooth position in same graft site PERIO CHARTING NARRATIVE
D4341 Periodontal scaling and root planing – four or more teeth per quadrant PERIO CHARTING
D4342 Periodontal scaling and root planing – one to three teeth per quadrant PERIO CHARTING
D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth PERIO CHARTING 
CODE DESCRIPTION INFORMATION NEEDED
D4999 Unspecified periodontal procedure, by report PERIO CHARTING NARRATIVE
D5899 Unspecified removable prosthodontic procedure, by report NARRATIVE
D6010 Surgical placement of implant body: endosteal implant X–RAYS
D6011 Second stage implant surgery NARRATIVE AND
X–RAYS
D6012 Surgical placement of interim implant body for transitional prosthesis: endosteal implant X–RAYS
D6040 Surgical placement: eposteal implant X–RAYS
D6050 Surgical placement: transosteal implant X–RAYS
D6051 Interim abutment NARRATIVE
D6080 Implant maintenance procedures when prostheses are removed and reinserted, including cleansing of prostheses and abutments  TOOTH CHART
D6081 Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure NARRATIVE
D6199 Unspecified implant procedure, by report NARRATIVE​
D6241* Pontic – porcelain fused to predominantly base metal X–RAYS
D6242* Pontic – porcelain fused to noble metal X–RAYS
D6245* Pontic – porcelain/ceramic X–RAYS
D6250* Pontic – resin with high noble metal X–RAYS
D6251* Pontic – resin with predominantly  base metal X–RAYS
D6252* Pontic – resin with noble metal X–RAYS
CODE DESCRIPTION INFORMATION NEEDED
D6710* Retainer crown – indirect resin  based composite X–RAYS
D6720* Retainer crown – resin with high  noble metal X–RAYS
D6721* Retainer crown – resin with predominantly base metal  X–RAYS
D6722* Retainer crown – resin with noble metal X–RAYS
D6740* Retainer crown – porcelain/ceramic X–RAYS
D6750* Retainer crown – porcelain fused to high noble metal  X–RAYS
D6751* Retainer crown – porcelain fused to predominantly base metal X–RAYS
D6752* Retainer crown – porcelain fused to  noble metal X–RAYS
D6999 Unspecified fixed prosthodontic procedure, by report NARRATIVE
D7921 Collection and application of autologous blood concentrate product NARRATIVE
D7999 Unspecified oral surgery procedure,  by report NARRATIVE
D8693 Re-cement or re-bond fixed retainer NARRATIVE
D8694 Repair of fixed retainers,  includes reattachment NARRATIVE
D8999 Unspecified orthodontic procedure,  by report NARRATIVE
D9930 Treatment of complications (post-surgical) – unusual circumstances, by report NARRATIVE
D9999 Unspecified adjunctive procedure,  by report NARRATIVE ​
 

 
* These codes are only reviewed for anterior teeth.
Documentation is only required if code is billed for a primary tooth.
 
Submit documentation by one of the following methods:
Mail -             SelectHealth Member Services
                     P.O. Box 30192
                     Salt Lake City, UT 84130
Email - mailto:memberservices@selecthealth.org
(in the subject line, type “Attention: Dental Documentation or X-rays”)​
(in the subject line, type “Attention: Dental Documentation or X-rays”)​
(in the subject line, type “Attention: Dental Documentation or X-rays”)​




© 2020 SelectHealth, All rights reserved.