Duplicate/Copy Patient's Records - CDT Code Guide
Overview
CDT code D9961 refers to the duplication or copying of a patient's dental records. This code is used when a patient requests a copy of their dental records for personal use, transfer to another dental practice, or for legal purposes. The process involves reproducing the patient's existing records, which may include charts, treatment plans, radiographs, and other pertinent documentation. This service ensures that patients have access to their dental history and can facilitate continuity of care when switching providers. It is a non-clinical procedure categorized under Adjunctive General Services, emphasizing its role in administrative and supportive functions within dental practice.
When to Use This Code
- When a patient requests a copy of their dental records for personal use.
- When transferring a patient's records to another dental practice.
- For legal purposes, such as providing documentation for a court case.
- When a patient is moving to a new location and needs to continue dental care elsewhere.
- To provide records to a specialist for consultation or referral purposes.
Documentation Requirements
- Patient's written request for record duplication.
- Documentation of the specific records copied and provided.
- Date of duplication and delivery to the patient or receiving party.
- Confirmation of patient's identity and authorization.
- Record of any fees charged for the duplication service.
Billing Considerations
When billing for D9961, it is important to note that this code typically does not involve insurance reimbursement as it is a non-clinical service. Practices may charge a reasonable fee for the duplication service, which should be communicated to the patient beforehand. Frequency limitations are generally not applicable, but it is crucial to ensure compliance with state and federal regulations regarding patient record handling and privacy.
Related CDT Codes
Frequently Asked Questions
Yes, dental practices may charge a reasonable fee for the duplication of records, which should be communicated to the patient in advance.
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