Attachment Dental Encounter & Order Form .pdf
PDF 204 KB Posted
- Solicitation number
- BPM058729
- Issued by
- Baltimore City, Maryland
About this file
This is a Dental Encounter & Order Form used by the Maryland Department of Juvenile Services (DJS) to document dental services provided to youth detained at facilities. The form captures essential clinical information including the date of service, youth demographic data (name, date of birth, assistance number, and sex), provider information, and health insurance plan details. The form accommodates multiple appointment types, including on-site dental clinic visits for new and returning patients, missed appointments with reasons documented, and off-site referrals with completion status tracking. The form is designed to streamline the recording of dental procedures and diagnoses for youth aged twelve to twenty years old who are referred by DJS medical staff.
The form provides comprehensive coding options for dental services across multiple categories, including diagnostic procedures (oral evaluations, radiographs), restorative treatments (amalgam and composite fillings), periodontal services (scaling and root planing), preventive care (prophylaxis and fluoride applications), endodontic procedures (pulp caps and root canals), and oral surgery (extractions). Additionally, the form includes ICD-9 diagnostic coding for common dental conditions such as dental caries, gingivitis, periodontal disease, and tooth impaction. The form requires documentation of contacts made during the encounter, referrals to other dental or medical providers when necessary, follow-up appointment scheduling with reasons for continued care, and provider authorization through signature and date. This standardized form ensures consistent documentation and tracking of dental services delivered at the Baltimore City Juvenile Justice Center dental suite.
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Text version
DJS Dental Encounter & Order Form
Maryland Department of Juvenile Services
DENTAL ENCOUNTER & ORDER FORM
Date of Service:_____________ Youth:______________________________________________________ DOB:_______________ Assist#:___________________Sex:_______
Provider: Health Ins. Plan:__________________________________________________________ None:_______
Type of Appointment
NR09 Dental Clinic on-site New Patient
Returning Patient
NR05 DNKA
Reason missed appointment:
NR0F Off-Site Referral –
Completed (check ICD-9)
NR0M Off-Site Referral missed
Reason:_________________________
CPT Codes - Dental
Diagnostic Restorative Periodontal Periodic Oral Evaluation D0120 Amal: 1 surf perm or dec D2140 Debride D4335
Limited Periodic Eval (Problem focused) D0140 Amal: 2 surf perm or dec D2150 Perio Scale: 5th/quad D4341
Comprehensive Oral Eval D0150 Amal: 3 surf perm or dec D2160 Perio Scale: ltd 1-3 th D4342
Single PA D0220 Amal: 4 surf perm or dec D2161 Desens (qd) D9910
Additional PA D0230 Comp: 1 surf ant D2330
Occl Xray D0240 Comp: 2 surf ant D2331 Oral Surgery
2 BW’s D0272 Comp: 3 surf ant D2332 Ext Dec D7111
Comp: 4 surf ant D2335 Ext: erupted th/exposed rts D7140
Preventive Comp: 1 surf post D2385 Ext surg D7210
Prophylaxis – Adult (14 & over) D1110 Comp: 2 surf post D2386 Surg Roots D7250
Topical Appl Fluoride - Adult D1204 Comp: 3+ surf post D2387 Brush Biopsy D7287
Prophylaxis- Child D1120 Sedative filling D2940
Topical Fluoride - Child D1203 Adjunctive
Sealant per tooth D1351 Pulp Cap Direct D3110 Pall Tx D9110
OHI D1330 Pulp Cap Indirect D3120 Local Anesthesia D9215
Nutrition Counseling D1310 Pulpotomy D3220 Rx D9630
Tobacco/Oral Hygiene D1320 Root Canal, 1 canal D3310 Occl Adj D9951
Unspec D9999
Other D0000
Diagnostic Codes (ICD - 9) Dental Abscess 522.5 Gingival/periodontal disease, unspec 523.9 Tooth impaction/eruption disorder 520.6
Dental Caries 521.00 Gingivitis/Acute 523.0 Tooth pain or tooth/gum disorder 525.9
Dental Exam V72.2 Oral aphthae 528.2 Other:
Other:
Contacts made this encounter Parent/Guardian Other dental provider Physician Other
Referrals (specify below if any referrals to another dental or medical provider is necessary) To: Reason: Time needed by:
FOLLOW UP
DENTAL
APPOINTMENT
◻None needed;
Dental care complete
◻Yes, F/U Needed Date for F/U: Reason for F/U:
ADDITIONAL ORDERS:
Provider Signature:_______________________________________________Date: _______________________
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