Full Mouth Debridement - CDT Code Guide
Overview
CDT code D4355 refers to a full mouth debridement procedure, which is a preliminary step to remove plaque and calculus that obstructs the dentist's ability to perform a comprehensive periodontal evaluation. This procedure is essential when a patient's oral hygiene is compromised to the point where a thorough examination cannot be conducted. Typically, this service is performed when there is an excessive build-up of plaque and calculus, making it difficult to assess the health of the gums and teeth accurately. It is not a substitute for a regular cleaning but rather a preparatory step to enable a detailed periodontal assessment at a subsequent visit.
When to Use This Code
- When a patient presents with heavy plaque and calculus build-up that prevents a comprehensive oral examination.
- Prior to a detailed periodontal evaluation when initial examination is not possible due to poor oral hygiene.
- In cases where the dentist cannot accurately diagnose periodontal conditions due to excessive debris.
- When initial probing depths are unattainable due to calculus interference.
- Before initiating a periodontal treatment plan that requires a clear assessment of the oral environment.
Documentation Requirements
- Detailed patient history and initial assessment notes indicating the need for debridement.
- Documentation of the extent of plaque and calculus build-up.
- Clinical notes explaining why a comprehensive periodontal evaluation could not be performed initially.
- Post-debridement assessment plans for a follow-up comprehensive periodontal evaluation.
- Patient consent for the procedure and understanding of the treatment plan.
Billing Considerations
D4355 is typically billed when a comprehensive periodontal evaluation cannot be performed due to excessive plaque and calculus. It is important to note that this code is not intended for routine prophylaxis and should not be used in conjunction with codes for regular cleanings. Insurance carriers may have specific frequency limitations, and it is advisable to verify patient benefits prior to treatment. Common modifiers may include those indicating the specific quadrant or area treated.
Related CDT Codes
Frequently Asked Questions
No, D4355 is intended to prepare the mouth for a comprehensive evaluation, which should be scheduled for a subsequent visit.
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