I frequently receive questions about what the cutoff age is for a child prophy versus an adult prophy. A prophylaxis is the removal of plaque, stains and calculus from tooth structures. It is intended to control irritational factors. It is PREVENTATIVE and NOT THERAPEUTIC.
Ok, that’s straight forward, so how do we know when to submit for a child prophy or an adult prophy? Well, when in doubt – go to the video tape….just kidding. I always refer back to the Descriptor, or the written narrative that provides further definition. It typically describes the intended use of the procedure code.
So let’s go to the video tape…
D1110 prophylaxis – adult
Removal of plaque, calculus and stains from the tooth structures in the permanent and transitional dentition. It is intended to control local irritational factors.
D1120 prophylaxis – child
Removal of plaque, calculus and stains from the tooth structures in the primary and transitional dentition. It is intended to control local irritational factors.
So the “ahah” moment……. the prophy codes are dentition specific not age specific.
Now for more confusion.
There are some dental benefits plans that have restrictions in their contracts that limit the available benefits or benefit levels based on age not stage of the dentition.
Back in 1991, The ADA adopted a policy (Age of Child (1991:635)) concerning this:
Benefits should be based on the STAGE of the dentition
If a plan cannot recognize the stage of the dentition, age 12 should be recognized as the age of an adult (excluding ortho treatment or sealants).
So based on this, for patients with a transitional dentition, the claim may be submitted as either a child or adult since the “transitional dentition” is included in both codes. For patients with an adult dentition (ie: eruption through the 2nd permanent molars) the claim may need to be appealed.
Having said that – prophy claims may still be rejected by carriers as “not meeting the plan age specifications” for this service.