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Coding Guide: Scaling & Polish for General Dentists in Abu Dhabi

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In this series of articles, we will explain the proper diagnosis for the procedures of scaling and polishing and documentation that adhere to the regulations for dental patients in Abu Dhabi, UAE.

The Diagnosis

Following ICD 10 Coding the best codes used are the following:

  • K03.6 DEPOSITS ACCRETIONS ON TEETH
  • K05.00 ACUTE GINGIVITIS, PLAQUE INDUCED
  • K05.10 CHRONIC GINGIVITIS, PLAQUE INDUCED

Coding Fact: K03.6 can be used as a diagnosis for teeth staining which can be used for the Bleaching procedure 97111 for 1 unit of time / 97112 for 2 units of time / 97113 units of time …etc

The procedures

  • Scaling: (11110):
    • It’s important to note the starting and ending time of each procedure as its a time unit procedure, each unit = 15 mins
    • For example, the patient had severe calculus, stains, and plaque and will require a longer time for scaling about 30 mins, thus the code used here will be 11112, if longer like about 45 mins that will mean about 3 units of time thus code 11113.
    • Documentation of the time is crucial, so in the documentation state that the procedure started at 5:15 and ended at 6:01, thus the code for this will be 11113.
  • Polish (11100) 
    • It’s important to note the starting and ending time of each procedure as its a time unit procedure, each unit = 15 mins
    • For example, the patient had severe calculus, stains, and plaque and will require a longer time for polishing about 30 mins, thus the code used here will be 11102, if longer like about 45 mins that will mean about 3 units of time thus code 11103.
    • Documentation of the time is crucial, so in the documentation state that the procedure started at 5:15 and ended at 6:01, thus the code for this will be 11103.

Examinations

  • Extra and Intra Oral examination ( with concentrations on conditions of the soft tissue that correlates with the diagnosis “Oral hygiene, gingiva, plaque, oral mucosa, and anything special.

Documentations

Here is an example of scaling and polishing documentation that adheres to the regulations of JAWADA and
Daman ( this isn’t a copy/paste sample):

The patient registered and entered your office at 5:05, File was open at 5:07

Patient, came to our clinic due to bleeding gums and discolorations of teeth ( Chief Complain), on visual examination we see severe amounts of calculus and gingivitis especially in the lower teeth (Local Examination), when asked the patient stated that he hasn’t cleaned his teeth in over a year and that he is a heavy smoker and coffee drinker (History). To resolve this issue scaling and polishing is required. Scaling was done with an ultrasonic scaler for 2 units of time from 5:15 pm till 5:45 Pm, Additionally, to provide a better appearance and remove the discolorations, polishing was required which was done in one unit of time from 5:45 till 6:00 PM (Procedure Details) this was done using airflow polish and prophylaxis brush with polish paste. once the procedure was done the patient reviewed his teeth and was very satisfied. (Procedure Outcome)
Materials used: (No anesthesia / Airflow powder / prophy paste)
Procedures done:

  • Scaling 2 units of time
  • Polish 1 unit of time

The patient left the office and the file was closed after documentations at 6:10.

It’s very important that the span of the procedures ( that use units of time) are done within the patient file opening and closing, in this case the procedure took around 45 mins + 6 mins examination = 51 mins in total , while the file opening and closing is between 5:07 till 6:10 which is around 63 mins which more than the procedures its self, BUT IT CAN NEVER BE LESS THAN THE PROCEDURE TIME, OR IT WILL BE REJECTED!!!

Another point, Thiqa will only accept scaling/polish with a time of 6 months between each repeating procedure, this means if the patient wants to do scaling/polish again withing less than 6 months from the previous visit it will not be accepted.

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About Author

Dr. Mohsen Saeed Ozaibi

MohsenSaeedOzaibi, A Dentist, Dental Manager at Emirates Jordanind Medical Center, Founder of OziDent.com. Graduated in 2009 with a Bachelor's Degree in Dental Science from Misr International University. A veteran in digital dental content publishing and marketing.

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