What should the D8660 chart note include?
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Pre-orthodontic treatment examination. RMH: Medical history reviewed/updates Chief complaint: Chief complaint Age: Age Dentition stage: Dentition stage Ortho records support: Radiographs/photos ordered by treating dentist and taken; scans/models Last dental visit/outstanding treatment: Date and untreated restorative/perio needs Malocclusion details: Class I/II/III, overbite/overjet/crossbite/crowding/esthetic concerns Treatment plan details: Limited/comprehensive, appliance type, estimated duration, anticipated outcome Retention plan: Fixed/removable retainers, wear schedule, follow-up Clinical examination: Clinical examination Extraoral: Extraoral Profile: Profile Facial symmetry: Facial symmetry TMJ evaluation: TMJ evaluation Intraoral: Intraoral Oral hygiene: Oral hygiene Periodontal status: Periodontal status Angle classification: Angle classification Overjet: Overjet Overbite: Overbite Crowding: Crowding Spacing: Spacing Crossbite: Crossbite Records obtained: Records obtained Photographs. Impressions/scans. Radiographs: Radiographs taken/reviewed and findings Treatment plan discussed: Plan/options reviewed. Options presented. Duration estimated. Fees reviewed. NV: Next visit
What documentation is required for D8660?
D8660 is documented as a growth-and-development monitoring exam, not a comprehensive evaluation. The note must demonstrate that the visit was clinical (vs records-only) and that a deliberate timing decision was made — start treatment, continue observation, or refer.
- Medical history review and update — meds, conditions, allergies, growth-relevant systemic factors (asthma / allergies and mouth-breathing pattern, endocrine or syndromic conditions affecting craniofacial growth, ADHD medications affecting bruxism/clenching). Pediatric growth context matters; "no changes" is acceptable but should be written.
- Chief complaint / parent concern — in the patient's or caregiver's own words. "Mom is worried about crowding" is a legitimate complaint; document it.
- Age and dentition stage — chronological age and the patient's current stage (primary, early mixed, late mixed, early permanent, permanent). Dentition stage drives the timing decision and is the single most important data point on a D8660 note.
- Eruption sequence and timing — which permanent teeth are present, expected, delayed, or ectopic. Compare to age-norms; flag ectopic canines, missing laterals, retained primaries, ankylosis. This is the growth in "growth and development."
- Skeletal and dental relationship findings — Angle classification (or "developing Class I/II/III"), overjet, overbite, crossbite (anterior/posterior, unilateral/bilateral), open bite, midline deviation, crowding, spacing. Patient-specific values, not "WNL."
- Facial / profile / TMJ assessment — symmetry, profile (straight/convex/concave), lip competence, mentalis strain, TMJ sounds or limited opening, masticatory muscle palpation. Brief but documented.
- Habits and airway — digit sucking, tongue thrust, mouth breathing, lip biting, bruxism. AAO and AAPD both flag habit identification at the pre-treatment exam as a documentation expectation.
- Periodontal and oral hygiene status — pre-ortho hygiene baseline; any gingivitis, calculus, or recession that needs to be addressed before banding.
- Outstanding restorative or perio needs — what must be resolved before active ortho can start. This is what gates the timing decision and is a high-yield audit item; "patient must complete restorative before band-up" is the kind of note that defends the visit.
- Imaging reviewed — pano, ceph, BWs, or photographs reviewed today. The films themselves (if exposed today) are billed under D0330 / D0340 / D0350 / D0210 / D0270 etc. — D8660 is not bundled with imaging codes. If a pano was exposed, document indication and findings.
- Timing decision — explicit. Three valid outcomes: (1) start treatment now (proceed to records and case presentation; do not bill D8660 if the same visit initiates active treatment), (2) continue observation with an interval and the specific finding being monitored, or (3) refer (to orthodontist, surgeon, or other specialist). The audit-defensible D8660 note states which of the three was chosen and why.
- Treatment plan discussion — what was reviewed with the family — limited vs interceptive vs comprehensive options if treatment is recommended, appliance possibilities, estimated duration, retention implications, and fee discussion if relevant. This is what makes the visit substantively pre-orthodontic and not a generic recall.
- Photographs or scans, if taken — note specifically and bill under their own codes (D0350, D0470). D8660 alone implies no records were captured today.
- Provider signature and any auxiliary operator initials.
Default-normal templating ("dentition stage WNL, no concerns, recall 6 months") is the most common D8660 documentation weakness. Auditors interpret a D8660 note that reads identically to every other D8660 in the practice as evidence that the visit was either a generic recall (downgrade to D0120) or a marketing touchpoint (downgrade to no charge). Patient-specific findings about eruption, skeletal pattern, or the specific finding being monitored are what make the note defensible.
Why does D8660 get denied?
The most common reasons D8660 is denied, downgraded, or recouped:
- No orthodontic rider — by far the most common cause. Many dental plans do not include orthodontic benefits at all; D8660 is denied as non-covered. Verify ortho coverage before billing.
- Bundled into the case fee — patient subsequently started active treatment with the same provider, and the carrier retroactively bundles the D8660 into the global D8080 / D8090 fee. Submitting D8660 within 30-60 days of active treatment initiation increases bundling risk.
- Same-day conflict with D8080-D8090 — D8660 billed alongside an active treatment code on the same DOS. Only the active treatment code pays.
- Same-day conflict with D9310 — billed for the same provider as D9310; the two are mutually exclusive on the same DOS.
- Default-normal documentation — the note reads identically to every other D8660 in the practice, with no patient-specific eruption, skeletal, or monitored-finding detail. Auditors downgrade to D0120 or deny.
- Adult patient (post-growth) — D8660 is specifically a growth-and-development code; many carriers deny when the patient's chronological age and dentition stage indicate completed growth. For adult ortho consultations, most carriers expect D9310.
- Frequency exceeded — second or third D8660 within a benefit year on a plan that limits to one. Carriers measure to the day.
- No documented orthodontic indication — the note doesn't identify a specific malocclusion, eruption concern, or skeletal pattern being monitored. Without an indication, the carrier reads the visit as a generic pediatric recall and downgrades to D0120.
- Missing prior authorization (Medicaid) — most state Medicaid programs and Medicaid MCOs require prior auth for D8660 with a Salzmann or HLD score documented; submitting without auth results in denial.
- Records-only visit miscoded as D8660 — D8660 is the exam; the records (D0330 / D0340 / D0350 / D0470) are separate. A "records day" with no clinical exam is not a D8660.
What do practices ask about D8660?
What's the difference between D8660 and D9310?+
D8660 is a pre-orthodontic monitoring visit specifically for growing patients, focused on if and when to start treatment. D9310 is a consultation by a dentist other than the practitioner providing treatment — typically the first referral evaluation, regardless of patient age or growth status. The first time a referred patient presents to an orthodontist for an evaluation, D9310 is often the more accurate code; the follow-up "let's check growth in 6 months" recall is D8660. For adult patients evaluating ortho, D9310 is almost always preferable because the growth-and-development descriptor doesn't fit.
Is D8660 the same as the initial orthodontic records appointment?+
No. D8660 is the clinical exam visit only. Comprehensive ortho records — panoramic radiograph (D0330), cephalometric radiograph (D0340), photographs (D0350), and study models or 3D scans (D0470) — are billed under their own codes. A clinical exam with records exposed the same day bills D8660 plus each records code; a records-only appointment with no exam is not a D8660. This is one of the most commonly miscoded patterns in pre-treatment orthodontics.
Can I bill D8660 multiple times for the same patient?+
Yes, in principle. D8660 is a periodic monitoring code — many growing patients are observed on 3-12 month intervals before treatment is initiated, and each documented monitoring visit is a separate D8660. Carrier frequency rules vary widely; some plans limit to one per provider per patient lifetime, others allow 1-2 per benefit year. Verify the patient's specific benefits before billing repeated D8660s.
Why do most orthodontic practices offer D8660 for free?+
Because most dental plans do not separately reimburse D8660 outside of orthodontic riders, and many ortho riders bundle D8660 into the global case fee once active treatment begins. The pre-treatment observation visit is a high-value relationship-building moment that often converts to active treatment, so most practices offer it as a no-charge marketing visit. The ADA still recommends submitting the code when an ortho benefit exists so that the patient's claim history accurately reflects the visit. Even when written off, the chart note should be defensibly documented as if the claim were paid.
Can I bill D8660 same-day as D8080?+
No. If active comprehensive orthodontic treatment is initiated the same date, the exam is bundled into the global D8080 / D8090 case fee. The same logic applies to D8010-D8040 (limited) and D8060-D8070 (interceptive). D8660 is a pre-treatment code; once active treatment starts, monitoring visits are D8670 and are typically bundled into the global ortho contract.
Does Medicaid cover D8660?+
Highly state-specific. Many state Medicaid programs cover D8660 under EPSDT screening expansions for growing patients with documented qualifying malocclusion (typically a Salzmann index or HLD score above threshold), but most condition coverage on prior authorization. Envolve, DentaQuest, and Liberty Dental MCOs follow state plans but enforce stricter prior-auth and documentation requirements. Submitting without prior auth or without a documented qualifying score results in denial in most state programs.
Can D8660 be used for adult orthodontic evaluations?+
Generally no. D8660 is specifically a growth-and-development monitoring code; the descriptor presumes a growing patient. For an adult considering orthodontics, D9310 (consultation) or D0150 (comprehensive evaluation) are the appropriate codes by scope. Many carriers automatically deny D8660 when the patient's chronological age indicates completed growth, regardless of documentation.