ADA Coding and UMB Financial Policies

Codes and Descriptions for clinical services rendered

Diagnostics

D0120 Periodic Oral Evaluation - Evaluation performed on a patient of record to determine any changes in the patient’s dental and medical health status since a previous comprehensive or periodic evaluation. Also known as the Recall Exam.

D0140 Limited Oral Evaluation - Problem Focused – An evaluation limited to a specific oral health problem or complaint. Also known as the Emergency Exam

D0170.2 Evaluation of Initial Therapy - This is code is entered when patients are appointed to reevaluate quadrant scaling at no charge.

Hygiene-only Screening: An evaluation performed on a family member, friend, or potential NERB patient who will be treated exclusively in the dental hygiene clinics and strictly for dental hygiene needs. The patient is under the care of a private dentist and will be seen by that dentist for all care not included in dental hygiene treatment. This may require interpretation of information acquired through additional diagnostic procedures (i.e. radiographs). The fee will be waived for spouse and children of students and NERB patients by completing a fee-adjustment form these forms can be found in the PCC office.

Though hygienists may collect and interpret the data used for these evaluations, only a dentist can perform the definitive evaluation.

Radiographic/Diagnostic Images

D0120 Intraoral Complete Series, including BW

D0220 Intraoral periapical first image,

D0230 Intraoral periapical each additional image

D0270 bitewing – single

D0272 bitewings- two images

D0274 bitewings- four images

D0330 Panoramic image

Preventive

D1120 Prophylaxis – child Removal plaque, calculus and stain from the tooth structures in the primary and transitional dentition. It is intended to control local irritational factors. Generally applies to a child under 12 yrs. of age.

D1110 Prophylaxis –Adult Removal of plaque, calculus and stain from the tooth structure in the permanent and transitional dentition. Generally applies to patients 12yrs and older.

D1208 Topical Application of Fluoride

D1351 Sealant per Tooth Mechanically and or chemically prepared enamel surface sealed to prevent decay

Periodontal Services

D4341 Periodontal Scaling and Root Planing – four or more teeth per quad this procedure involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. It is indicated for patients with periodontal disease and is therapeutic, not prophylactic, in nature.

D4342 Periodontal Scaling and Root Planing – one to three teeth per quad. See definition above

D4910 Periodontal Maintenance Procedures This procedure is instituted following periodontal therapy and continues at varying intervals, determined by clinical evaluation, for the life of the dentition or implant placement. If new or recurring periodontal disease appears, additional diagnostic and treatment procedures must be considered.

D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report such as Arestin or Periochip

UMB Fee Schedule 2016/2017

Updated 6/2016

*whitening refills are $35. and charged as an office visit THIS MUST BE DONE BY MIL BOYD or SHARON CHENOWITH ONLY

Financial Policy

Fees and Insurance

Our patients customarily pay for their treatment at each visit. We accept direct payment from several dental insurance plans, with prior authorization. Before insurance authorization, we must receive complete information about your plan.

In several of our clinics, individual payment plans and other arrangements may be made.

We take pride in the quality of care we provide at the University of Maryland Dental School. Here, you will find a dedicated staff to help you learn about the clinic best suited to your needs. Dental and dental hygiene students provide the majority of the treatment, supervised by a faculty engaged in teaching, research and patient care. At the Dental School, caring for you – and caring about you – is our goal. We can help you prevent dental disease, and can provide complete dental care for you and your family. Before we begin any treatment, we will conduct a complete examination to determine the best course of dental care. Our faculty review and evaluate all treatment provided by students. Your care may take longer, but you are assured of personal attention and supervision.

For additional policies on insurance and fees visit the UMB website under patient information.

Reduced Fee Schedule (UG-) Guide

1. Patients qualify for the UG- fees based on an income scale determined by the Federal Government and the number of people being supported by that income. An application and proof of income must be submitted. The patient must be in comprehensive care before applying for reduced fee schedule.
2. The receptionist looks at the Axium Maintenance Card to determine that the patient has been awarded the Reduced Fee Schedule.
3. A Reduced Fee Schedule is then attached to the patient account by the Business manager. This will automatically override the regular fee and only charge the patient from the reduced schedule.

Screening Hygiene - ONLY Patients

When dental hygiene students wish to screen family members, friends or potential NERB patients, they are required to do the following to treat these patients in the pre-doctoral clinic:

1. Get a patient registration (hygiene only) slip from the Patient care Coordinator’s (PCC) office.
2. Take registration slip to the front desk on the first floor (screening desk). The patient information will then be entered in the computer and a chart will be made.
3. The patient should report to the screening clinic a half hour before it opens for either the 9:00 am or 1:00 pm session.
4. Pick up the patient’s chart from Cheryl Manus in the radiology clinic.
5. Bring patient back to the screening clinic to review medical history and take the appropriate radiographs.
6. ALL children must be screened through the pediatric clinic.

Screening Fee for Family:

Hygiene student’s spouse, children and NERB patients will not be charged a fee and therefore need to complete a fee reduction form for this service.

For FY 2016-2017 student’s parents and siblings will be 50% of the UG fee schedule.

Obtain this form from the PCC to bring in family, etc.

Outcome Assessment/Patient Account Adjustment Form