Clinical Documentation Requirements

Northeast Delta Dental Clinical Documentation Requirements

Quality radiographs and legible written documentation are necessary to make an accurate benefit determination. Non-diagnostic radiographs and illegible written documentation will be returned, and benefit determination will be delayed. On occasion, Northeast Delta Dental’s professional reviewers will request diagnostic or post-operative radiographs concerning other procedures, not listed below, to assist them in their benefit determinations. Post-treatment reviews and requests for radiographs will also be made on a random basis to verify treatment.

Radiographs

Northeast Delta Dental now scans all radiographs. It is very important that all intraoral radiographs, particularly complete series, should be mounted prior to sending them to Northeast Delta Dental for review. It is also essential to indicate “Left” and “Right” on all radiographs. Please mark the dentist’s name and address as well as the patient’s name.

Individual Consideration

Remember to include a brief narrative on a claim when a higher fee is being charged due to circumstances, reflecting additional time and/or materials. Without calling this to our attention, your submitted fee will be reduced to your fee on file.

Northeast Delta Dental’s professional reviewers may require radiographs or other documentation before approving payment where individual consideration of a higher fee is requested.

Radiographs Being Submitted For Predetermination or Payment

Unless previously predetermined, all claims for the procedures below will require charting and/or x‑rays as indicated.

If more than one quadrant is predetermined, it is not necessary to submit charting and x‑rays with each claim for payment. Simply fill in the date(s) of service on the original Predetermination Voucher, or a photocopy of it, or make a note on the claim indicating the predetermination number. (You may use the COMMENTS section on electronic claims to indicate this information.)

Radiographically Evident?

If a condition is not radiographically evident to you, it may not be evident to our professional reviewers. Please make note of any existing conditions which can only be seen clinically, so that our professional reviewers can make benefit determinations based on all the facts the first time through.

All required clinical documentation may be submitted as electronic attachments. For more information, please contact Tesia-PCI at 800-724-7240 or info@Tesia.com.

The following procedures routinely require submission of diagnostic radiographs and periodontal charting for benefit determination purposes:

  • D4260 Osseous Surgery (including flap entry and closure) – per quadrant – 4 or more teeth
  • D4261 Osseous Surgery (including flap entry and closure) – per quadrant – 1 to 3 teeth
  • D4263 Bone replacement graft – first site in quadrant
  • D4264 Bone replacement graft – each additional site in quadrant
  • D4274 Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area)

The following procedures routinely require submission of periodontal charting only for benefit determination purposes:

  • D4210 Gingivectomy or gingivoplasty – per quadrant
  • D4211 Gingivectomy or gingivoplasty – per quadrant - 1 to 3 teeth
  • D4240 Gingival flap procedure, including root planing – per quadrant
  • D4241 Gingival flap procedure, including root planing – per quadrant, 1 to 3 teeth

The following procedure requires a narrative and photo, if available. Procedure is not covered when performed on the same date of service as a crown or restoration:

  • D4249 Clinical crown lengthening – hard tissue

The following procedures routinely require submission of clinical notes and diagnostic radiographs.

  • D7210 Surgical removal of erupted tooth 
  • D7220 Removal of impacted tooth - soft tissue
  • D7230 Removal of impacted tooth - partially bony
  • D7240 Removal of Impacted tooth - completely bony
  • D7241 Removal of impacted tooth - completely bony with unusual surgical complications
  • D7250 Surgical removal of residual tooth roots (cutting procedure)
  • D7251 Coronectomy - intentional partial tooth removal

This document is available for download. 

Rev. 110111