I was advised that our dental hygienist cannot diagnose a patient but in ICD10, if a patient comes in for a prophy, should they use the two following diagnosis? If so, if the abnormal dental cleaning is used, the hygienist would have to add the abnormal diagnosis. At this point, does the dental provider have to add an addendum stating the abnormality? What is required?
Dental cleaning Z01.20
Dental cleaning with abnormal finding Z01.21
If abnormal findings exist the provider must add to the documentation agreeing to the findings.
American Dental Coders Association
3120 W Carefree Hwy. Suite 1
Phoenix, AZ. 85086