D1110 - Prophylaxis (Adult)
Removal of plaque, calculus and stains.
- Procedure Code
- D1110
- Category
- Preventive
Insurance Verification Benchmarks & Billing Guidelines
Benchmark Policy Source: Delta Dental National / PPO Standard
- Frequency Limitation
- 2 per calendar year or 1 per 6 consecutive rolling months (CALENDAR_YEAR)
- Age Limitation
- Mandatory age 14 and older. Patients under 14 must be billed as D1120.
Required Claim Attachments & Pre-Submission Checklist
- Clinical chart note confirming removal of plaque, calculus, and stains
- Patient age verified as 14 or older
Bill When (Allowable Clinical Criteria)
- Preventive cleaning on patient with healthy periodontium or localized mild gingivitis
- Adult dentition (age 14+)
Restrictions & Clinical Exclusions
- Do NOT bill on same day as scaling and root planing D4341/D4342
- Do NOT bill on same day as D4346 (scaling in presence of generalized gingivitis)
- Do NOT bill for active periodontitis patients (use D4910 maintenance instead)
Common Claim Denial Codes & Overturn Strategies
| Denial Code | Denial Reason | Appeal & Overturn Strategy |
|---|---|---|
| CO-119 | Exceeded 2 per year benefit limit | Check if plan has rolling 6-month rule vs calendar year rule. |
| CO-97 | Bundled into periodontal therapy performed on same date | Cannot bill prophylaxis with SRP on same date. Fees are not billable to patient. |
ICD-10 Justification & Crosswalk Mappings
| ICD-10 Code | Diagnosis Name | Category | Primary Justification | Claim Type | Clinical Scenario |
|---|---|---|---|---|---|
| K03.6 | Deposits [accretions] on teeth | Other diseases of hard tissues of teeth | Yes (Primary) | BOTH | prophylaxis – adult indicated for Deposits [accretions] on teeth |
| E10.9 | Type I diabetes mellitus without complications | Diabetes mellitus | Secondary | BOTH | prophylaxis – adult indicated for Type I diabetes mellitus without complications |
| E11.A | Type 2 diabetes mellitus without complication in remission | Diabetes mellitus | Secondary | BOTH | prophylaxis – adult indicated for Type 2 diabetes mellitus without complication in remission |
| E11.9 | Type 2 diabetes mellitus without complications | Diabetes mellitus | Secondary | BOTH | prophylaxis – adult indicated for Type 2 diabetes mellitus without complications |
| K05.1 | Chronic gingivitis | Gingivitis and periodontal diseases | Secondary | BOTH | prophylaxis – adult indicated for Chronic gingivitis |
| K05.10 | Chronic gingivitis, plaque induced | Gingivitis and periodontal diseases | Secondary | BOTH | prophylaxis – adult indicated for Chronic gingivitis, plaque induced |
| K05.11 | Chronic gingivitis, non-plaque induced | Gingivitis and periodontal diseases | Secondary | BOTH | prophylaxis – adult indicated for Chronic gingivitis, non-plaque induced |
| K05.30 | Chronic periodontitis, unspecified | Gingivitis and periodontal diseases | Secondary | BOTH | prophylaxis – adult indicated for Chronic periodontitis, unspecified |
| K05.311 | Chronic periodontitis, localized, slight | Gingivitis and periodontal diseases | Secondary | BOTH | prophylaxis – adult indicated for Chronic periodontitis, localized, slight |
| K05.312 | Chronic periodontitis, localized, moderate | Gingivitis and periodontal diseases | Secondary | BOTH | prophylaxis – adult indicated for Chronic periodontitis, localized, moderate |
| K05.313 | Chronic periodontitis, localized, severe | Gingivitis and periodontal diseases | Secondary | BOTH | prophylaxis – adult indicated for Chronic periodontitis, localized, severe |
| K05.319 | Chronic periodontitis, localized, unspecified severity | Gingivitis and periodontal diseases | Secondary | BOTH | prophylaxis – adult indicated for Chronic periodontitis, localized, unspecified severity |
| Z33.1 | Pregnant state, incidental | Pregnant state | Secondary | BOTH | prophylaxis – adult indicated for Pregnant state, incidental |
| Z72.0 | Tobacco Use | Problems related to lifestyle | Secondary | BOTH | prophylaxis – adult indicated for Tobacco Use |