Please circle appropriate diagnostic codes cpt

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Please circle appropriate diagnostic codes

CPT: (American Medical Codes)

70486	Computed Tomography, Maxillofacial area without contrast	70310	Radiologic examination, complete full mouth
76376	3D rendering with interpretation	70320	Radiologic exam, partial, less than full mouth
76380	Computed Tomography, localized study	70328	Radiologic exam, tempomandibular joint, open and closed

ICD-10 Codes: (International Medical Codes)

J32.9	Unspecified chronic sinusitis	K08.3	Retained dental root
K00.1	Supernumerary teeth	K08.401	Partial edentulism, class I
K00.6	Disturbances in tooth eruption (impaction)	K08.402	Partial edentulism, class II
K03.0	Excessive attrition	K08.403	Partial edentulism, class III
K04.8	Radicular cyst (apical, periapical)	K08.404	Partial edentulism, class IV
K05.21	Aggressive periodontitis, localized	K08.409	Partial edentulism, unspecified
K05.22	Aggressive periodontitis, generalized	K08.419	Loss of teeth due to trauma
K08.101	Complete edentulism, class I	K08.429	Loss of teeth due to periodontal disease
K08.102	Complete edentulism, class II	K08.439	Loss of teeth due to caries
K08.103	Complete edentulism, class III	K08.499	Other loss of teeth
K08.104	Complete edentulism, class IV	K09.0	Developmental odontogenic cysts
K08.20	Atrophy edentulous alveolar	M26.62	Arthralgia of temporomandibular join
K08.21	Minimal atrophy of mandible	M26.69	TMJ sounds on openings and/or caries
K08.22	Moderate atrophy of mandible	M27.2	Inflammatory conditions
K08.23	Severe atrophy of mandible	R20.8	Other disturbance of skin sensation
K08.24	Minimal atrophy of maxilla	S02.5XXA	Tooth broken/fractured due to trauma, closed
K08.25	Moderate atrophy of maxilla	S02.5XXP	Tooth broken/fractured due to trauma, open
K08.26	Severe atrophy of maxilla

ADA Codes: (Dental Codes)

D0360	CB CT-craniofacial data	D0368	CB CT capture and interpretation for TMJ series including two or more exposures
D0362	CB 2D multi image reconstruction	D0380	CB CT image capture with limited field of view – less than one whole jaw
D0363	CB 3D multi image reconstruction	D0381	CB CT image capture with field of view of one full dental arch – mandible
D0364	CB CT capture and interpretation with limited field view – less than whole jaw	D0382	CB CT image capture with field of view of one full dental arch – maxilla
D0365	CB CT capture and interpretation with limited field of one full dental arch – mandible	D0383	CB CT image capture with field of view of both jaws, with or without cranium
D0366	CB CT capture and interpretation with field of view of one full dental arch – maxilla	D0384	CB CT image capture for TMJ series including two or more exposures
D0367	CB CT capture and interpretation with field of view of both jaws – with or without cranium	D0391	Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report

Please circle the Region of Interest (ROI)

Orthodontics
Sinus Exam
Endodontics

Airway Assessment
Dental Impaction
Oral Pathology

Implants
TMJ Exam

Maxilla
Mandible
Both Arches

Appointment Details

Preferred Reproduction Format

CD
Glossy Prints
Via Internet
Radiological Report
All of the above

**Please circle appropriate diagnostic codes on back**

Implant brand: _____________________________

Viewing Software: ______________________

Special Instructions:

_____________________________________________________________________________________________________________________________________________________________________________________________

Indicate teeth or
area of interest:

1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16
32	31	30	29	28	27	26	25	24	23	22	21	20	19	18	17

Scheduling Information

Date of Appt: _____________ Exact Location: _________________________________________________________

Time: ___________________ _________________________________________________________

Referring Doctor Information

REFERRAL FORM

Name: _________________________________________ Acct Number: ____________________________________

Address: _______________________________________ E-mail: __________________________________________

Phone: ________________________________________ Fax: ____________________________________________

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