Prophylaxis — Adult Template

Adult prophylaxis.

RMH: Medical history reviewed/updates
BP: BP/Pulse

Prophy code support: Adult/child code supported by dentition/plan age rules
Disease status: Preventive procedure; localized/mild gingivitis only or healthy/supportive periodontal status
Implants cleaned: Implants/restorations cleaned if present
Plaque/calculus/stain amount: Amount and areas

Periodontal Assessment:
Gingival condition: Gingival condition
Probing depths: Probing depths/periodontal chart reference.
Bleeding on probing: Bleeding on probing
Plaque score: Plaque score
Calculus: Calculus

Prophylaxis Procedure:
Ultrasonic scaling.
Hand scaling.
Polishing with prophy paste.
Flossing.

Areas of concern: Areas of concern

OHI: Instructions reviewed.
Brushing technique reviewed.
Flossing technique reviewed.
Recommended products: Recommended products

Fluoride: Fluoride product

Radiographs: Radiographs taken/reviewed and findings

Doctor exam: Provider/exam findings.

Findings discussed: Findings reviewed with patient/guardian.

Treatment recommended: Treatment recommended

Complications: None or describe.
Patient tolerance: Tolerance/response.

NV: Next visit

Documentation requirements

Because D1110 is preventive, the chart needs to prove the periodontal status that justifies a preventive (not therapeutic) code — not just that a cleaning happened. A defensible note includes:

• Medical history review and update — meds, conditions, allergies, recent hospitalizations or surgeries. State what changed; "no changes" is acceptable but should be written rather than omitted.
• Vitals — BP and pulse. Required by many state boards and most sedation-capable practices on every adult visit.
• Periodontal status that supports the preventive code — explicitly: healthy, supportive, or localized/mild gingivitis only with no bone loss and no attachment loss. This single line is what separates a defensible D1110 from a misreported D4346 or D4910.
• Periodontal screening or charting — probing depths (or PSR), bleeding on probing distribution (localized vs generalized; specific sites or BOP %), recession, mobility, furcation. BOP >30% with generalized inflammation triggers a D4346 consideration; this note has to make clear you didn't meet that threshold.
• Plaque and calculus distribution and amount — supragingival vs subgingival; light/moderate/heavy; localized sites. This is the patient-specific risk anchor that carriers and auditors look for.
• Dentition statement supporting D1110 vs D1120 — note adult/permanent dentition (or transitional with all permanent teeth erupted). When a patient is plan-age "child" but clinically adult dentition, document the dentition rationale and submit a narrative.
• Implants and implant-borne restorations — if present, document that they were cleaned and the peri-implant tissue findings (healthy vs mucositis vs peri-implantitis). The CDT 2021 descriptor explicitly includes implants under D1110.
• Procedure performed — ultrasonic scaling, hand scaling, polishing (selective vs full-mouth), flossing. The four-line procedural recap in the body is the minimum.
• Oral hygiene instruction — patient-specific: which technique, which sites, which products. Generic boilerplate ("OHI given") is a known audit-flag pattern.
• Fluoride — if applied, document varnish (D1206) vs other-delivery topical (D1208) — these are not interchangeable, and D1208 is excluded from many adult plans. Adult fluoride is most defensible when paired with a documented caries-risk rationale (root caries, xerostomia, head/neck radiation, high decay rate).
• Radiographs reviewed — interpretation only; the films themselves are billed under their own codes.
• Doctor evaluation findings — when the dentist's exam is the same date, it is billed separately as D0120 (or D0150 / D0180 by scope). The dentist's findings line in the prophy note documents that the eval happened; the eval itself is its own note.
• Findings reviewed with patient and any treatment recommendations.
• Complications — explicitly noted, even if "none."
• Patient tolerance / response.
• Next visit — recall interval and what's planned.

The "amnesia test" applies: a third party reading the note must be able to reconstruct what was scaled, what the periodontal status was, and why this was D1110 and not D4346 or D4910. Default-normal autotext (every patient with the same gingival findings) is a known recoupment pattern in Medicaid OIG audits.

Common denial reasons

The most common reasons D1110 is denied, downgraded, or recouped:

• Frequency exceeded — third cleaning in 12 months without documented caries-risk or pregnancy rationale; or visit booked 1–2 days short of the carrier's strict 6-month rule.
• Combined-frequency violation — a mid-year D4346 or D4910 used the second cleaning slot already.
• D1110 billed on a perio patient — chart history shows D4341/D4342 or D4910 within the carrier's lookback, and the carrier expects D4910 indefinitely. Reverting to D1110 on a perio-treated patient is a common Delta and Cigna downgrade.
• D1110 same-day as D4346 or SRP — the D4346 descriptor explicitly disallows same-day D1110 / D4341 / D4342 / D4355. Submitting both on the same DOS results in one being denied or bundled.
• Bone loss / pocketing on the chart — radiographs and probing depths in the chart show generalized moderate-severe periodontitis, but the cleaning was billed as D1110. Carrier downgrades or recoups; auditors flag as upcoding-by-omission.
• Generalized moderate-severe gingival inflammation, no bone loss — the correct code was D4346, not D1110. Some carriers will downgrade D1110 to a non-covered status if the chart documents BOP >30% with generalized inflammation.
• Adult code billed on plan-age "child" patient — when the patient is under the plan's adult age but has full permanent dentition, the carrier may auto-process as D1120 unless a narrative explains the dentition rationale.
• Implant-only "prophy" on an edentulous patient with implant-supported prosthesis — some carriers question D1110 when there are no remaining natural teeth, since 2021 descriptor language allows it but plan documents may require a different implant-maintenance code.
• Default-normal templating — every D1110 chart note in the practice reads identically, with the same gingival findings and the same "moderate generalized calculus." State Medicaid OIG audits cite this pattern routinely.
• No documentation of periodontal status — the prophy note doesn't state probing depths, BOP, or gingival condition; auditors can't tell whether D1110 or D4346 was correct, and recoup the lower-supported code.
• Missing fluoride documentation when fluoride was billed alongside — D1206 vs D1208 confused or unsupported; the prophy claim is paid but the fluoride is denied.

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