D1120 - Prophylaxis (Child)
Removal of plaque, calculus and stains.
- Procedure Code
- D1120
- Category
- Preventive
Insurance Verification Benchmarks & Billing Guidelines
Benchmark Policy Source: Delta Dental National / PPO Standard
- Frequency Limitation
- 2 per calendar year or 1 every 6 months (CALENDAR_YEAR)
- Age Limitation
- Under age 14 (covered through age 13). In absence of group contract language, a person age 14+ must be billed as adult prophy D1110.
Required Claim Attachments & Pre-Submission Checklist
- Patient date of birth verified as under age 14 on date of service
- Plaque, calculus, and stain removal documented
Bill When (Allowable Clinical Criteria)
- Routine cleaning for child in primary or transitional dentition under age 14
Restrictions & Clinical Exclusions
- Do NOT bill once patient reaches 14th birthday (switch to D1110)
Common Claim Denial Codes & Overturn Strategies
| Denial Code | Denial Reason | Appeal & Overturn Strategy |
|---|---|---|
| CO-119 | Patient age 14 or older on date of service | Submit corrected claim updating procedure code to D1110 (Adult Prophylaxis). |
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 – child indicated for Deposits [accretions] on teeth |
| E10.9 | Type I diabetes mellitus without complications | Diabetes mellitus | Secondary | BOTH | prophylaxis – child indicated for Type I diabetes mellitus without complications |
| E11.A | Type 2 diabetes mellitus without complication in remission | Diabetes mellitus | Secondary | BOTH | prophylaxis – child indicated for Type 2 diabetes mellitus without complication in remission |
| E11.9 | Type 2 diabetes mellitus without complications | Diabetes mellitus | Secondary | BOTH | prophylaxis – child indicated for Type 2 diabetes mellitus without complications |
| K05.1 | Chronic gingivitis | Gingivitis and periodontal diseases | Secondary | BOTH | prophylaxis – child indicated for Chronic gingivitis |
| K05.10 | Chronic gingivitis, plaque induced | Gingivitis and periodontal diseases | Secondary | BOTH | prophylaxis – child indicated for Chronic gingivitis, plaque induced |
| K05.11 | Chronic gingivitis, non-plaque induced | Gingivitis and periodontal diseases | Secondary | BOTH | prophylaxis – child indicated for Chronic gingivitis, non-plaque induced |
| K05.30 | Chronic periodontitis, unspecified | Gingivitis and periodontal diseases | Secondary | BOTH | prophylaxis – child indicated for Chronic periodontitis, unspecified |
| K05.311 | Chronic periodontitis, localized, slight | Gingivitis and periodontal diseases | Secondary | BOTH | prophylaxis – child indicated for Chronic periodontitis, localized, slight |
| K05.312 | Chronic periodontitis, localized, moderate | Gingivitis and periodontal diseases | Secondary | BOTH | prophylaxis – child indicated for Chronic periodontitis, localized, moderate |
| K05.313 | Chronic periodontitis, localized, severe | Gingivitis and periodontal diseases | Secondary | BOTH | prophylaxis – child indicated for Chronic periodontitis, localized, severe |
| K05.319 | Chronic periodontitis, localized, unspecified severity | Gingivitis and periodontal diseases | Secondary | BOTH | prophylaxis – child indicated for Chronic periodontitis, localized, unspecified severity |
| Z33.1 | Pregnant state, incidental | Pregnant state | Secondary | BOTH | prophylaxis – child indicated for Pregnant state, incidental |
| Z72.0 | Tobacco Use | Problems related to lifestyle | Secondary | BOTH | prophylaxis – child indicated for Tobacco Use |