Understanding Dental Code D1355

When to Use D1355 dental code

The D1355 dental code is designated for the application of a caries preventive medicament, per tooth. This code is most appropriate when a patient, particularly a child or an adult at elevated caries risk, receives a topical medicament that is not a traditional fluoride varnish or gel. Use D1355 when applying materials such as silver diamine fluoride (SDF) or other non-fluoride agents specifically to prevent caries on a tooth that does not yet have a cavity. It should not be used for restorative procedures or for fluoride treatments that are covered under D1206 or D1208.

Documentation and Clinical Scenarios

Accurate documentation is crucial for successful billing and claim acceptance. Best practices include:

• Charting the specific tooth number where the medicament was applied.
• Noting the patient’s caries risk assessment and rationale for choosing a non-fluoride preventive agent.
• Describing the medicament used (e.g., SDF) and the clinical indication (e.g., deep grooves, early demineralization, high caries risk).
• Documenting patient or guardian consent when using agents like SDF, which may have side effects such as staining.

Common scenarios include pediatric patients with erupting molars, adults with exposed root surfaces, or patients with special healthcare needs who may not tolerate traditional restorative care.

Insurance Billing Tips

Billing for D1355 requires attention to payer policies and thorough documentation. Here are actionable steps:

• Verify coverage during insurance verification calls, as not all carriers reimburse D1355. Ask specifically about preventive medicament coverage beyond fluoride.
• Submit detailed clinical notes with the claim, including caries risk assessment and the medicament used.
• Use per-tooth billing: D1355 is billable per tooth, so indicate the exact teeth treated on the claim form.
• Appeal denied claims by providing supporting documentation, such as risk assessments, progress notes, and evidence-based guidelines supporting the use of the chosen medicament.
• Monitor EOBs (Explanation of Benefits) for partial payments or denials, and follow up promptly with additional information if requested.

Staying proactive with insurance verification and documentation reduces AR (accounts receivable) days and improves reimbursement rates.

Example Case for D1355

A 7-year-old patient presents for a routine exam. The hygienist identifies deep pits and fissures on the newly erupted first permanent molars, with no evidence of caries but a high risk due to family history and dietary habits. The provider applies silver diamine fluoride to teeth #3 and #14 and documents the procedure, risk assessment, and parental consent. The claim is submitted using D1355 for each treated tooth, with supporting clinical notes attached. The insurance carrier initially denies the claim, but upon appeal with additional documentation, payment is approved.

This real-world scenario highlights the importance of proper code selection, documentation, and persistence in insurance follow-up for successful billing of D1355.