D6545 Patient Encounter Form
User Manual: D6545
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DENTAL NETWORK OF AMERICA PATIENT ENCOUNTER FORM PLEASE PRINT AND FILL IN ALL BLANKS DATE OF SERVICE MO DAY YR MEMBER I.D. # (SEE ELIGIBILITY LIST) FIRST NAME OF SUBSCRIBER ADA CODE PROVIDER LICENSE # CENTER NUMBER STATE PN# FIRST LAST NAME LAST NAME (IF DIFFERENT FROM PATIENT) GROUP NUMBER D4000-D4999 PERIODONTICS D4210 Gingivectomy/4+ teeth D4240 Ging Flap incl Rt. Plane/4+ teeth D4260 Osseous Surg./4+ teeth ADA TOOTH # & SERVICE CODE SURFACE/QUAD D6200-D6999 PROSTHODONTICS (FIXED) D6241 Pontic/Porcelain Base Metal D6545 Ret. For Resin Bonded Br. D6751 Crown/Porcelain Base Metal D6752 Crown/Porcelain Noble Metal D6791 Crown/Full Cast Base Metal D6930 Recement Bridge D6970 Post and Core, Indirect Fab D6972 Prefab Post and Core D6999 Use for Con't care Appts. D6 D6 D6 D0470 Diagnostic casts D4270 Pedicle Soft Tiss Graft D6 D0 D0 D4341 Perio Sc. Rt. Plane/4+ teeth D4355 Full Mouth Debridement D6 D0 D4910 Perio Maintenance D7140 Ext. erupted tooth/exp root D0120 D0140 D0150 D0160 D0210 D0220 D0230 D0240 D0272 D0274 D0330 D0460 TOOTH # & SURFACE/QUAD SERVICE D0100-D0999 DIAGNOSTIC Periodic Oral Eval. Limited Oral Eval. Comprehensive Oral Eval. Detailed/Extensive Oral Eval. Intraoral Comp. Series Intraoral Periapical 1st Intraoral Periap. Ea. Add. Intraoral Occlusal Bitewing - Two Films Bitewing - Four Films Panoramic Film Pulp Vit. Test D1000-D1999 PREVENTIVE ADA CODE PATIENT BIRTH DATE D3110 D3120 D3220 D3310 D3320 D3999 D3 D3 SERVICE TOOTH # & SURFACE/QUAD D3000-D3999 ENDODONTICS Pulp Cap Direct/Exc Rest Pulp Cap Ind/Exc Rest Theraputic Pulpotomy Endodontic Therapy - Anterior Endodontic Therapy - Bicuspid Use for Con't care Appts. D7000-D7999 ORAL SURGERY D4999 Use for Con't care Appts. D7310 Alveo with Ext./4+ teeth D1110 Prophylaxis, Adult D4 D7320 Alveo not with Ext./4+ teeth D1120 Prophylaxis, Child D4 D7999 Use for Con't care Appts. D1203 Fl Excl Pro Child D5000-D5899 PROSTHODONTICS (REMOVABLE) D5110 Complete Upper Denture D1351 Sealant - Per Tooth D7 D7 Space Maintainer D5120 Complete Lower Denture D7 D1999 Use for Con't care Appts. D5130 Immediate Upper Denture D7 D1 D5140 Immediate Lower Denture D7 D1 D5211 Upper Partial - Resin D7 D1 D1 D5212 D5213 D5214 D5410 D5411 D5421 D5422 D5510 D5520 D5610 D5620 D5630 D5640 D5750 D5751 D5760 D5761 D5899 D5 D5 D5 D5 D5 D5 D5 D5 D5 D5 D5 D5 D15 D2140 D2150 D2160 D2161 D2330 D2331 D2332 D2335 D2391 D2392 D2393 D2740 D2750 D2751 D2791 D2950 D2951 D2952 D2954 D2999 D2 D2 D2 D2 D2000-D2999 RESTORATIVE Amal 1 Surface Amal 2 Surface Amal 3 Surface Amal 4+ Surface Resin 1 Surf Anterior Resin 2 Surf Anterior Resin 3 Surf Anterior Resin 4+ Surf Anterior Resin 1 Surf Posterior Resin 2 Surf Posterior Resin 3 Surf Posterior Crown/Porcelain Crown/Porcelain Hi Noble Crown/Porcelain Base Metal Crown/Full Cast Base Metal Core Build Up w/Pins Pin Ret In add to Rest/Tooth Post and Core, Indirect Fab Prefab Post and Core Use for Con't care Appts. © Dental Network of America 12/08 Lower Partial - Resin Upper Partial - Metal Lower Partial - Metal Adj Complete Denture Upper Adj Complete Denture Lower Adj Partial Denture Upper Adj Partial Denture Lower Repair Comp Denture Base Repl Teeth Comp Denture Ea. Repair Resin Base Repair Framework Repair/Replace Clasp Replace Broken Tooth Each Reline Comp Upper Denture Reline Comp Lower Denture Reline Upper Partial Denture Reline Lower Partial Denture Use for Con't care Appts. Current Dental Terminology @ American Dental Association. D7 D9000-D9999 ADJUNCTIVE GENERAL SERVICES D9110 Palliative Treatment D9951 Occlusal Adj Limited D9952 Occlusal Adj Complete D9999 Use for Con't care Appts. D9 D9 D9 LIST ALL PROCEDURES OVER MAX OR NOT COVERED ADA CODE SERVICE FEE COLLECTED INSTRUCTIONS FOR COMPLETION ON REVERSE SIDE INSTRUCTIONS FOR COMPLETING THE PATIENT ENCOUNTER FORM Please complete all necessary information. All procedures are listed by ADA code and blank lines are available so you may write in any procedures not included on the form. Use only ADA codes. Forms that are missing information will be returned to the dental office. 1. Refer to your eligibility list while completing the top section of the form. 2. Check each procedure performed and add tooth# and surface when appropriate. 3. Use one line per procedure code. 4. Submit only one procedure code for procedures which require more than one appointment to complete, example: endodontics, dentures, crown and bridge. For continued care appointments, use the 999 code in the appropriate category for try-in and delivery of prosthetics and endodontic completion appointments. 5. Services over the patient’s annual maximum or non-covered services should be reported in the lower right box. List the ADA code, service description and the fee for service collected. 6. Submit PEFs to DNoA by the 20th of the month. All treatment data received by the 20th of the month will be reported in that month’s utilization. Treatment data received after the 20th will be keyed in the following month’s utilization. LABORATORY AND PROSTHETIC FUND REIMBURSEMENT Some subscribers are members of groups which offer dental laboratory reimbursement. Follow the instructions below for submitting laboratory bills: 1. Once the procedure is completed, attach the original laboratory statement(s) to the Patient Encounter Form. 2. Include the patient’s name and member I.D. number, procedure code and tooth#(s) on the laboratory statement. 3. Non-covered laboratory charges are the patient’s financial responsibility, for example: precision attachments or characterizations. 4. Lab bills received after 365 days of the date of service will not be processed Mail all completed forms directly to: Dental Network of America P.O. Box 23089 Belleville, IL 62223-0089 12/08
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