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Suggested Documentation for Oral Hygiene Counseling (D1330), Nutritional Counseling (D1310), and Tobacco Counseling (D1320) Evidence-Based Dental Plans
Some evidence-based dental plans provide benefits for one oral hygiene instruction, nutritional counseling or tobacco counseling visit each year for patients assessed at moderate to high risk for dental caries or periodontal disease using the PreViser Oral Health Information Suite. Moderate to high risk is indicated by risk score of 3 or greater.
Clinical notes for the date of service should document the specific topics discussed with the patient. Submission of clinical notes or narratives is not required when claims are submitted but may be requested for quality assurance purposes.
Oral hygiene instructions (D1330)
Documentation should include instructions for home care including but not limited to tooth brushing technique, flossing, use of oral hygiene aids as well as use of prescription and over the counter antimicrobial rinses, irrigants, or dentifrices for control of bacterial plaque or remineralization of tooth structure.
Nutritional counseling for control and prevention of oral disease (D1310)
Documentation should include the patient’s current dietary habits including consumption of sugared beverages and other cariogenic foods and counseling on food selection and dietary habits as a part of the treatment and control of periodontal disease and caries. Include any specific recommendations for diet changes including the use of sugar free alternatives such as xylitol gum.
Tobacco counseling for control and prevention of oral disease (01320)
Documentation should include information about the type and frequency of tobacco use and discussion of the increased risk for oral cancer, periodontal disease and other conditions. If the dentist is not providing direct tobacco counseling with follow up at subsequent appointments, the record should document that the patient was referred to medical tobacco cessation program or provided information about self-directed cessation program such as a Tobacco Quit Line. Document any prescriptions written or recommendations made for anti-smoking medications including nicotine patches or gum.
Caries Susceptibility Tests (D0425)
Documentation should include what condition you are testing, the brand of the diagnostic test kit you are using, and the result of the test. Include any specific information about what the results of the test achieved for the dental practice and how this information will be used for patient education.*
*Please be aware of the difference between the caries susceptibility test code (D0425) and the caries risk assessment codes (D0601, D0602, D0603). The caries susceptibility test code (D0425) is covered under the HOW enhanced preventive benefit. The caries risk assessment codes (D0601, D0602, D0603) are standardly covered under most benefit plans with narrative especially Delta.