D9110 Palliative Treatment Template (Per Visit)

The template

Pick your PMS to format the placeholders, then copy.

PMS format

[Prompt:"name"]

Palliative treatment for emergency relief.

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

CC: Chief complaint
Duration of symptoms: Duration of symptoms
Pain level (0-10): Pain level 0-10

Symptoms: Symptoms
Pain character: Pain character
Temperature sensitivity: Temperature sensitivity
Spontaneous pain: Spontaneous pain
Swelling: Swelling

Clinical Exam:
Tooth/teeth: #Tooth number(s)
Percussion: Percussion response
Palpation: Palpation response
Cold test: Cold test response

Radiographs: Radiographs taken/reviewed and findings
Radiographic findings: Radiographic findings

Dx: Diagnosis

Palliative code support: Patient complaint and non-definitive pain-relief procedure performed
Definitive care plan: Definitive treatment that may follow

Treatment rendered: Treatment rendered

Rx: Prescription or none

Post-op instructions: Instructions reviewed.
Patient advised: Temporary relief; definitive treatment needed.

Recommended definitive tx: Recommended definitive tx

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

NV: Next visit

Field glossary

What each placeholder represents.

Medical history reviewed/updates
Confirm RMH was reviewed today and note any changes — medications, conditions, allergies, anticoagulants, recent procedures relevant to the focal complaint.
BP/Pulse
Vital signs taken at the visit. Important when anesthesia, analgesics, or antibiotics may be administered or prescribed.
Chief complaint
The patient's complaint in their own words, in quotes — establishes the pain that triggered the palliative visit.
Duration of symptoms
How long the patient has had the pain (e.g., '3 days,' 'since last night,' '2 weeks').
Pain level 0-10
Pain severity at presentation; capture both peak and resting if they differ.
Symptoms
Specific symptoms reported — localized vs diffuse, swelling, bad taste, trismus, lymphadenopathy, sleep disruption.
Pain character
Quality of the pain — sharp, dull, throbbing, electric, pressure-like — and what makes it better or worse.
Temperature sensitivity
Cold/hot response — duration, severity, lingering vs brief.
Spontaneous pain
Whether the patient experiences pain without provocation; frequency and duration of episodes.
Swelling
Presence, location, and extent of swelling — localized to one tooth/site, facial, lymph nodes — or 'none.'
Tooth number(s)
Universal tooth number(s) or arch/quadrant of the symptomatic tooth and any opposing or adjacent teeth involved.
Percussion response
Response to vertical and lateral percussion on the suspect tooth and at least one control tooth.
Palpation response
Response to apical, buccal, and soft-tissue palpation; note tenderness or fluctuance.
Cold test response
Cold test response on the suspect tooth and a control tooth — duration and character (sharp, lingering, no response).
Radiographs taken/reviewed and findings
Specific imaging captured today (with CDT codes if billed separately) or prior images reviewed; diagnostic-quality statement.
Radiographic findings
Findings tied to the diagnosis — caries depth, restoration proximity to pulp, PARL, bone levels, impaction angle, periodontal status.
Diagnosis
Specific diagnosis with tooth/area (e.g., 'symptomatic irreversible pulpitis #19,' 'acute pericoronitis #32,' 'occlusal traumatism #14') — generic 'tooth pain' is insufficient.
Patient complaint and non-definitive pain-relief procedure performed
The load-bearing element for D9110: state the complaint addressed and describe the specific palliative procedure performed (irrigation, occlusal relief, sedative dressing, recementation, soft liner, smoothing) with clinical detail. This is what proves the code.
Definitive treatment that may follow
The recommended definitive procedure that today's visit deferred — RCT, extraction, restoration, surgical management — establishing that today's care was palliative and not definitive.
Treatment rendered
The full list of work performed today, billed under separate codes when applicable (D0140 for the eval, D9110 for the palliative procedure, imaging codes for any radiographs).
Prescription or none
Drug, dose, sig, quantity, refills — or 'none' with a brief rationale. A Rx alone does not support D9110, but a Rx written in addition to the procedure is appropriate documentation.
Instructions reviewed
Post-op or self-care instructions given verbally and/or in writing — diet, hygiene, return precautions.
Temporary relief; definitive treatment needed
Short statement to the patient (and chart) that today's care was temporary; definitive treatment is still required and is recommended/scheduled.
Recommended definitive tx
The specific recommended definitive procedure with code if known (e.g., 'D7230 surgical extraction #32,' 'D3330 RCT #19') and any referral made.
None or describe
Any complications during the palliative procedure, or 'none.'
Tolerance/response
Patient's tolerance of the procedure and immediate response (e.g., 'pain reduced from 7/10 to 2/10 on departure').
Next visit
Scheduled or recommended next appointment with purpose (e.g., 'OMS consult within 1-2 weeks,' 'RCT #19 in 5 days, 90 min').

Documentation requirements

A defensible D9110 chart note has to prove three things: (1) the patient was in pain, (2) you performed a hands-on procedure, and (3) the procedure was non-definitive — definitive treatment will follow. The required elements:

Chief complaint quoted in the patient's own words — establishes the pain that triggered the palliative visit
HPI — onset, duration, severity (1-10), character, triggers, prior self-treatment (OTC analgesics, abx, home remedies)
RMH update and BP — especially if anesthesia was used or analgesics/abx prescribed
Focused clinical exam of the symptomatic tooth/area — percussion, palpation, mobility, soft tissue, swelling, sinus tract; cold/EPT when indicated
Imaging interpretation — PA, BW, or pano taken/reviewed (billed separately under D0220/D0270/D0330) with the radiographic interpretation tied to the diagnosis
Specific diagnosis with tooth/area — "symptomatic irreversible pulpitis #19," "pericoronitis #32," "occlusal traumatism #14," "fractured cusp #30." Generic "tooth pain" is insufficient.
The palliative procedure performed, in clinical detail — what you actually did. This is the load-bearing element. Examples that defend the code:
- "Pericoronitis #32: chlorhexidine irrigation of operculum; occlusal relief of #2 mesiolingual cusp with fine diamond, <1 mm reduction, polished"
- "Sedative dressing (IRM) placed in deep occlusal cavity #19 to seal exposed dentin and relieve cold sensitivity; no caries removal performed"
- "Selective occlusal adjustment #14 — articulating paper marks identified premature contact in MIP; relieved with football diamond, occlusion rechecked"
Anesthesia administered (if any) — agent, concentration, carpules, site. D9215 (local) is bundled into most procedure codes but is reportable separately for some payers when only D9110 is performed.
Why this is palliative, not definitive — one sentence stating that the underlying pathology requires definitive treatment that was not done today (e.g., "RCT or extraction recommended; patient declined treatment today due to time/finances and elected palliative care to control symptoms")
Definitive treatment plan and follow-up — what is recommended and when (e.g., "RCT #19 scheduled in 5 days; ibuprofen 600 mg q6h prn until then")
Prescriptions — agent, dose, sig, quantity, refills (Rx alone never supports D9110, but a Rx written in addition to the procedure is appropriate documentation)
Post-op instructions and return precautions
Provider signature and assistant initials

The single most common audit failure on D9110 is a chart note that describes the diagnosis and the recommended treatment but not the palliative procedure that was actually performed. If a reviewer cannot point to a specific clinical action that relieved pain, the code will be downgraded or denied. The ADA's D9110 Guide specifically calls out that "writing a prescription is not, by itself, a procedure that supports D9110."

Some carriers (multiple state Medicaid MCOs, Envolve Dental, DentaQuest) require a narrative or by-report explanation when D9110 is billed alongside same-day evaluation or imaging codes — keep the procedural description tight and clinically specific so it can be lifted directly into a claim narrative if requested.

Common denial reasons

The most common reasons D9110 is denied, downgraded, or audited:

No procedure documented — Rx-only encounter. The ADA's D9110 Guide is explicit that a prescription alone does not support the code. If the chart says "diagnosed irreversible pulpitis, prescribed ibuprofen and amoxicillin, scheduled RCT," the visit is D0140 alone, not D0140 + D9110.
Vague procedural description. "Palliative treatment rendered" with no clinical specifics fails review. Auditors expect to see what tool, what site, what the patient response was.
Same-tooth bundling with definitive treatment. D9110 + D7140 same DOS, same tooth. D9110 + D3220 same DOS, same tooth. D9110 + D2391/D2940 same DOS, same tooth. All routinely denied as inclusive.
Multiple D9110 lines same DOS. D9110 is per visit. Two or three lines for separate teeth or quadrants get bundled to one.
No separately identifiable evaluation. If only D9110 is billed and no D0140 is reported (or vice versa), some carriers will flag the claim for missing context — pair them when both occurred.
Used as a substitute for D9951/D9952. Routine occlusal adjustment for a non-emergency high spot or a splint check is not palliative; it's an occlusal adjustment code. Carriers downgrade D9110 to the appropriate code or deny.
Used during the global period of a recently completed procedure. Post-op pain management on a tooth you just extracted/RCT'd is typically D0171 (post-op re-eval), not D9110.
Teledentistry billing. D9110 cannot be performed via synchronous teledentistry — there is no hands-on procedure. Encounters submitted with D9995 + D9110 are routinely denied.
Pediatric pattern billing. Repeated D9110 across multiple visits for the same patient/quadrant during a staged pediatric treatment plan triggers Medicaid OIG review.
Missing tooth/area number. Several Medicaid MCOs require a specific tooth number or quadrant on the D9110 line — a missing area-of-oral-cavity field auto-denies the claim.
Missing provider signature — auto-flagged by automated audits.