Encounter for dental exam and cleaning w abnormal findings

This code signifies a patient visit for routine dental care, specifically a check-up and prophylaxis, during which the dentist identifies one or more deviations from normal oral health. These findings could range from minor issues like gingivitis or early caries to more significant concerns requiring further investigation or treatment.

Apply this code when a patient presents for a preventive dental examination and cleaning, and the dentist documents any abnormal findings. This includes situations where a new problem is discovered or an existing, previously undiagnosed condition is identified during the preventive visit.

• Always sequence this code as the primary diagnosis when the encounter is for the examination and cleaning itself, even if abnormal findings are present.
• Code all specific abnormal findings identified during the encounter as secondary diagnoses to provide a complete clinical picture.
• Do not use this code if the primary reason for the visit is to address a known dental problem or symptom, even if a cleaning is also performed.