Question

What are the age ranges for the child and for the adult prophy?

There is no standard age among dental plans for differentiating an adult prophy from a child prophy. Most Delta Dental carriers use age 14 to differentiate an adult prophy from a child prophy. Some dental trusts use age 15. Some carriers use age 12. Other carriers have no age criteria.

It is all over the board. The ADA instructs providers to bill an adult prophy for patients who have transitional dentition or permanent dentition.  The ADA says to bill a child prophy for patients with primary dentition or transitional dentition. So there is a clear overlap for those patients with
transitional dentitions. The ADA says it is the dentist's discretion as to which code to use when the patient has transitional dentition.

In the FAQ section of CDT, the ADA's past policy is for carriers to use age 12 if they need a specific age for processing claims. However, that is just the ADA's formal opinion. It is not law. The carriers can set whatever age they choose as an alternative benefit.

If a patient is frustrated because you code an adult prophy for a patient who is 12 or 13, show them the FAQ in the CDT book. In fact, make a copy of it, and have them take it to their employer benefits manager. That is who has the clout to change the age criteria for their dental plan. They may be more inclined to do so when they see the ADA's formal guidance.

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