Apicoectomy Premolar - CDT Code Guide
Overview
CDT code D3421 is used to describe an apicoectomy procedure on the first root of a premolar tooth. This surgical procedure involves the removal of the apex, or tip, of the tooth's root to eliminate infection and promote healing. It is typically performed when a root canal treatment has failed or when there is persistent infection or inflammation at the root tip. During the procedure, the dentist will access the root through the gum tissue, remove the infected tissue, and seal the end of the root. This code does not include the placement of retrograde filling material, which may be necessary depending on the case. If multiple roots require treatment, refer to code D3426.
When to Use This Code
- Persistent infection at the root tip after root canal therapy
- Chronic inflammation in the periapical area of a premolar
- Presence of a cyst or granuloma at the root apex
- Failed previous apicoectomy requiring retreatment
- Structural complications preventing traditional root canal treatment
Documentation Requirements
- Detailed clinical notes describing the diagnosis and necessity for the procedure
- Radiographic evidence supporting the need for an apicoectomy
- Pre-operative and post-operative radiographs
- Description of the procedure performed, including the specific root treated
- Patient consent forms and any relevant medical history
Billing Considerations
When billing for D3421, ensure that the procedure is clearly documented and justified by clinical findings. This code is specific to the first root of a premolar and does not include retrograde filling, which may require additional coding. Be aware of any frequency limitations set by the patient's insurance plan and consider using modifiers if multiple procedures are performed in a single visit. Coordination with insurance providers is recommended to confirm coverage and reimbursement policies.
Related CDT Codes
Frequently Asked Questions
D3421 is for apicoectomy on the first root of a premolar, while D3426 covers apicoectomy on each additional root.
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