Coding with Kyle: Are dental sealants ever covered by dental insurance?

Dental coding can be tricky business. In order to collect what they are owed, dental offices need to know the correct codes to submit to insurance companies. The monthly column Coding with Kyle can help!

Nov 23rd, 2016
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D1351 Sealant per tooth

By the end of this article you will understand when to bill for sealants and how to successfully code for the procedure(s) being performed. Let’s start by understanding the CDT description, which defines the use and purpose. According to the CDT, a sealant is a mechanically and/or chemically prepared enamel surface sealed to prevent tooth decay.

Let’s discuss limitations and reasons for denial

Age limitations exist with almost every dental plan.
If you incorrectly code for D1351 Sealant Placement when the treatment performed was a D1352 Preventive Resin Restoration or D2391 Resin-based Composite Restoration.
Reporting multiple tooth surfaces per tooth to maximize reimbursement can lead to an alternate benefit for reimbursement of only the occlusal surface.
Replacing a sealant that has been placed and reported to the same insurance company within the last six to 12 months can lead to a denial of coverage.

Common coding errors

Billing for sealant placement beyond the age limitations of the patient’s dental insurance, i.e., adult placement
Billing for placement on primary teeth (typically not reimbursed)
Billing for sealants in the presence of caries (tooth decay)
Billing for third molar sealant placement, i.e., wisdom teeth

It is always recommended that you preauthorize dental treatment to ensure coverage.

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