Dental code D9610 is used to report the administration of therapeutic drugs by injection, excluding anesthesia. Proper documentation and understanding of this code can help ensure appropriate reimbursement and avoid claim denials.

What is D9610?

D9610 refers to the administration of a single therapeutic drug via injection, commonly used in dental procedures to manage pain, infection, or inflammation. The injection is typically administered intramuscularly (IM) or subcutaneously (SC) and may include antibiotics, steroids, or anti-inflammatory medications.

When Should D9610 Be Used?

Use D9610 when:

• A therapeutic drug is injected as part of dental treatment (e.g., corticosteroid for TMJ inflammation, antibiotic injection for severe infection, or analgesic for pain management).

• The injection is separate from local anesthesia (D9219 or D9215 should be used for local anesthetic administration).

• The drug is medically necessary and documented as part of the treatment plan.

When NOT to Use D9610

• For intravenous (IV) drug administration – Use the appropriate IV sedation or medication code instead.

• For local anesthetic injections – These are covered under separate anesthesia codes.

• If the medication is taken orally or applied topically – This code is strictly for injectable drug administration.

Billing and Insurance Considerations

• Insurance coverage varies – Some plans may cover injections if deemed medically necessary, while others may deny the claim as non-covered.

• Check prior authorization requirements – Some insurers may require approval before administering certain injectable drugs.

• Multiple injections may need separate documentation – If multiple injections are administered during the same visit, clarify this in the treatment notes and check if a modifier is required.

• Include drug details – Some insurers may require the name, dosage, and reason for administration in the claim submission.

Best Practices for Documentation

To ensure proper reimbursement and compliance:

• Record the drug name, dosage, and lot number in the patient’s chart.

• Document the reason for administration, linking it to the patient’s condition.

• Include a procedural note detailing the site of injection and patient response.

• Submit supporting documentation, such as clinical notes, to justify the need for the injection.

Conclusion

Using D9610 correctly ensures that therapeutic drug injections are properly billed and reimbursed. By following insurance guidelines, maintaining thorough documentation, and verifying coverage beforehand, dental providers can effectively utilize this code while providing necessary patient care.