For Dates of Service Before January 1, 2014

Dental Hygienist Allowable Services

Dental hygienists may be reimbursed for the following procedures only:

• D0191 — Assessment of a patient.
• D1110 — Prophylaxis — adult.
• D1120 — Prophylaxis — child.
• D1206 — Topical application of fluoride varnish.
• D1208 — Topical application of fluoride.
• D1351 — Sealant — per tooth.
• D4341 — Periodontal scaling and root planing — four or more teeth per quadrant.
• D4342 — Periodontal scaling and root planing — one to three teeth per quadrant.
• D4355 — Full mouth debridement to enable comprehensive evaluation and diagnosis.
• D4910 — Periodontal maintenance.
• D0999 — Unspecified diagnostic procedure, by report.

Procedure codes D0191 or D0999 must be used to indicate an oral screening or preliminary examination. Providers using procedure code D0999 are required to indicate "preliminary examination" or "oral screening" in Element 30 of the ADA 2006 Claim Form or the ADA 2012 Claim Form. These terms must be used on the claim forms because D0999 is also used to indicate a HealthCheck "Other Service." On occasion, a HealthCheck screening may identify the need for health care services that are not otherwise covered by ForwardHealth or that exceed limitations. These services are called HealthCheck "Other Services." HealthCheck "Other Services" require PA. Use of the terms "preliminary examination" or "oral screening" indicates that services are not HealthCheck "Other Services" and do not require PA or a HealthCheck referral.

Providers are required to obtain PA for certain specified services before delivery of that service. The procedure codes that always require PA are D4341, D4342, and D4910. Procedure code D4355 requires PA when performed on children through the age of 12.

Refer to the appropriate dental service category (i.e., diagnostic, preventative, or periodontics) for coverage limitations.