Version 2024

2024 ICD-10-CM Diagnosis Code Z01.21

Encounter for dental examination and cleaning with abnormal findings

ICD-10-CM Code:: Z01.21
ICD-10 Code for:: Encounter for dental exam and cleaning w abnormal findings
Is Billable?: Yes - Valid for Submission
Code Navigator:

Code Information
Approximate Synonyms
Clinical Classification
Tabular List of Diseases and Injuries
Index to Diseases and Injuries References
Code Edits
Present on Admission (POA)
Convert to ICD-9 Code
Patient Education
Other Codes Used Similar Conditions
Code History

Code Classification

Factors influencing health status and contact with health services
(Z00–Z99)
- Persons encountering health services for examinations
  (Z00-Z13)
  - Encounter for other special examination without complaint, suspected or reported diagnosis
    (Z01)

Z01.21 is a billable diagnosis code used to specify a medical diagnosis of encounter for dental examination and cleaning with abnormal findings. The code is valid during the current fiscal year for the submission of HIPAA-covered transactions from October 01, 2023 through September 30, 2024. The code is exempt from present on admission (POA) reporting for inpatient admissions to general acute care hospitals.

This code describes a circumstance which influences the patient's health status but not a current illness or injury. The code is unacceptable as a principal diagnosis.

Approximate Synonyms

The following clinical terms are approximate synonyms or lay terms that might be used to identify the correct diagnosis code:

Dental caries susceptibility - finding
Susceptible to caries

Clinical Classification

Clinical Category	CCSR Category Code	Inpatient Default CCSR	Outpatient Default CCSR
Any dental condition including traumatic injury	DEN001	X - Not applicable.	N - Not default outpatient assignment for principal diagnosis or first-listed diagnosis.
Caries, periodontitis, and other preventable dental conditions	DEN003	X - Not applicable.	N - Not default outpatient assignment for principal diagnosis or first-listed diagnosis.
Medical examination/evaluation	FAC014	X - Not applicable.	Y - Yes, default outpatient assignment for principal diagnosis or first-listed diagnosis.
Nontraumatic dental conditions	DEN002	X - Not applicable.	N - Not default outpatient assignment for principal diagnosis or first-listed diagnosis.

Tabular List of Diseases and Injuries

The following annotation back-references are applicable to this diagnosis code. The Tabular List of Diseases and Injuries is a list of ICD-10-CM codes, organized "head to toe" into chapters and sections with coding notes and guidance for inclusions, exclusions, descriptions and more.

Use Additional Code

code to identify abnormal findings

Index to Diseases and Injuries References

The following annotation back-references for this diagnosis code are found in the injuries and diseases index. The Index to Diseases and Injuries is an alphabetical listing of medical terms, with each term mapped to one or more ICD-10-CM code(s).

- Admission (for) - See Also: Encounter (for);
- - examination at health care facility (adult) - See Also: Examination; - Z00.00
  - - dental - Z01.20
    - - with abnormal findings - Z01.21

- Dental - See Also: condition;
- - examination - Z01.20
  - - with abnormal findings - Z01.21

- Examination (for) (following) (general) (of) (routine) - Z00.00
- - dental - Z01.20
  - - with abnormal findings - Z01.21
- - teeth - Z01.20
  - - with abnormal findings - Z01.21

Code Edits

The Medicare Code Editor (MCE) detects and reports errors in the coding of claims data. The following ICD-10-CM Code Edits are applicable to this code:

Unacceptable principal diagnosis - There are selected codes that describe a circumstance which influences an individual's health status but not a current illness or injury, or codes that are not specific manifestations but may be due to an underlying cause. These codes are considered unacceptable as a principal diagnosis.

Present on Admission (POA)

Z01.21 is exempt from POA reporting - The Present on Admission (POA) indicator is used for diagnosis codes included in claims involving inpatient admissions to general acute care hospitals. POA indicators must be reported to CMS on each claim to facilitate the grouping of diagnoses codes into the proper Diagnostic Related Groups (DRG). CMS publishes a listing of specific diagnosis codes that are exempt from the POA reporting requirement. Review other POA exempt codes here.

CMS POA Indicator Options and Definitions

POA Indicator	Reason for Code	CMS will pay the CC/MCC DRG?
Y	Diagnosis was present at time of inpatient admission.	YES
N	Diagnosis was not present at time of inpatient admission.	NO
U	Documentation insufficient to determine if the condition was present at the time of inpatient admission.	NO
W	Clinically undetermined - unable to clinically determine whether the condition was present at the time of inpatient admission.	YES
1	Unreported/Not used - Exempt from POA reporting.	NO

Convert Z01.21 to ICD-9-CM

ICD-9-CM Code: V72.2 - Dental examination
Approximate Flag - The approximate mapping means there is not an exact match between the ICD-10 and ICD-9 codes and the mapped code is not a precise representation of the original code.

Patient Education

Dental Health

It's important to take care of your mouth and teeth starting in childhood. If you don't, you could have problems with your teeth and gums - like cavities or even tooth loss.

Here's how to keep your mouth and teeth healthy:

Brush your teeth twice a day with a fluoride toothpaste
Clean between your teeth every day with floss or another type of between-the-teeth cleaner
Snack smart - limit sugary snacks
Don't smoke or chew tobacco
See your dentist or oral health professional regularly

NIH: National Institute of Dental and Craniofacial Research

[Learn More in MedlinePlus]

Dental Exam

What is a dental exam?

A dental exam is part of a checkup of your teeth and gums. When you see your dentist for a checkup, the visit usually includes three parts:

A dental cleaning to remove the buildup of plaque, a sticky film of bacteria that coats your teeth
X-rays of your teeth on certain visits, depending on the health of your teeth
An exam of your teeth and mouth by a dentist

Dental exams are important for protecting your oral health. Oral health includes your teeth, gums, and all the muscles and bones that let you smile, speak, and chew. Common oral health problems, such as include tooth decay (cavities) and gum disease (periodontal disease), can lead to pain, infection, and tooth loss.

Poor oral health can affect your general health, too. For example, loosing teeth can cause problems with eating and nutrition, which can lead to other health problems. You can help prevent oral health problems with regular visits to the dentist and good toothbrushing and flossing habits at home.

At a dental checkup, you'll usually see both a dentist and a dental hygienist. A dentist is a doctor who has special training to care for teeth and gums. A dental hygienist is a health care professional trained to clean teeth and teach you how to take good care of your teeth and gums.

Dentists can treat people of all ages. There are also pediatric dentists who have received additional training on dental care for children.

Other names: dental checkup, oral exam, oral hygiene, dental hygiene, dental prophylaxis

What is it used for?

Dental exams are used to:

Clean teeth to help prevent tooth decay, gum disease, and other oral health problems
Find problems early when they're easier to treat
Help people learn the best ways to care for their oral health

Why do I need a dental exam?

Ask your dentist or hygienist how often you should have exams. Most adults and children need to have a routine dental exam every six months. You may need more frequent dental exams if you:

Have gum disease
Get a lot of cavities
Have a family history of oral health problems
Have a health condition that may increase your risk for oral health problems, such as:
- Diabetes
- Heart disease
- HIV
- Conditions that affect your immune system
Take medicines that make your mouth dry
Smoke
Are pregnant, which increases your risk for gum disease

If you have swollen, dark red, and/or bleeding gums, tooth pain, or other discomfort in your mouth, don't wait for your routine dental exam. Contact your dentist as soon as possible.

Babies should have their first dental appointment within six months of getting their first tooth, or by their first birthday. Ask your baby's dentist how often your baby should have a dental exam. Most babies should be checked every six months.

What happens during a dental exam?

At a typical dental exam, a hygienist will clean your teeth. Then the dentist will examine your mouth. At certain visits, you may have x-rays of your teeth before the dentist examines you.

Dental x-rays can show hidden cavities, gum disease, bone loss in your jaw, and other problems that can't be seen by looking in your mouth. Ask your dentist how often you need x-rays.

For a dental cleaning:

The first step is called "scaling." The hygienist will use small, metal tools to scrape plaque and tartar from your teeth:
- Plaque is a film of bacteria that begins to coat your teeth soon after you eat. Brushing and flossing removes plaque, but not all of it. If you let plaque build up on your teeth, it can cause cavities and destroy the tissue and bone around your teeth, leading to tooth loss. Scaling gets rid of the plaque that tooth brushing leaves behind.
- Tartar is a hard substance that can form over time from plaque that's not removed from your teeth. Tartar can build up along your gumline and cause red, swollen gums (gingivitis). This can lead to more serious gum infections and tooth loss. Only a professional dental scaling can remove tartar. And regular professional dental cleanings can prevent it from forming.
Next the hygienist will polish your teeth, using a device like an electric toothbrush with a rubber tip. The polishing is done with a special paste that's slightly gritty.
After the polishing, the hygienist will floss your teeth.
When needed, the hygienist may apply a fluoride gel or foam, or dental sealants to your teeth:
- Fluoride is a mineral that prevents tooth decay (cavities). Fluoride treatments are given to children more often than adults.
- Sealants are thin coatings painted on the chewing surfaces of the back teeth. They can help prevent cavities for many years by keeping food and bacteria out of the grooves in the teeth. Sealants are mostly used in children and teens. But adults who have never had cavities in their back teeth may also choose to protect those teeth with dental sealants.
The hygienist or dentist may give you tips on how to care for your teeth and gums, including the right way to brush and floss.

If dental x-rays are needed:

Your upper body will be covered with a heavy lead apron to protect you from radiation.
You'll bite down on a piece of plastic and an x-ray scanner will be positioned near your cheek.
The hygienist will leave the room or stand behind a protective shield to take the x-ray, which only takes a few seconds.
You'll repeat these steps a few times to get x-rays of all your teeth.

For the dentist's exam:

If you had x-rays, your dentist will check them for problems.
Next, your dentist will:
- Examine your teeth and gums.
- Check your bite, which is the way your top and bottom teeth fit together. If you have a bite problem, you may be referred to an orthodontist.
- Check you for oral cancer. This involves looking and feeling for unusual lumps in your mouth, including on your lips and tongue. Your dentist may also check your face and neck.

Will I need to do anything to prepare for a dental exam?

If you have certain health conditions, you may need to take antibiotics before your exam to prevent infections. Ask your dentist and/or your health care provider whether you need antibiotics, especially if you have heart problems or an immune system disorder.

Some people feel anxious about going to the dentist. If you or your child feels this way, tell your dentist before your visit. Your dentist can discuss ways to help you feel more relaxed about getting dental care.

Are there any risks to a dental exam?

There is very little risk to having a dental exam. The cleaning may be uncomfortable, but it's usually not painful.

Dental x-rays are safe for most people. The dose of radiation in an x-ray is very low. But x-rays are not recommended during pregnancy, unless it's an emergency. Be sure to tell your dentist if you are pregnant or think you may be pregnant.

What do the results mean?

After your dental exam, your dentist will discuss any oral health problems you may have and your treatment options. For certain problems, improving your brushing and flossing habits may be all that's needed.

If you or your child has a cavity or a more serious problem, you'll probably need to make another appointment with the dentist to treat it.

Learn more about laboratory tests, reference ranges, and understanding results.

Is there anything else I need to know about a dental exam?

You can help keep your teeth for your lifetime by getting regular dental exams and taking good care of your teeth and gums. For a healthy mouth and strong teeth:

Brush your teeth twice a day using a soft-bristled brush and toothpaste with fluoride.
Clean between your teeth regularly using dental floss, a special brush, or a plastic pick. Your dentist can suggest the best way to do this.
Replace your toothbrush every three or four months.
Eat a healthy diet and limit sweets and sugary drinks. If you do have sweets, brush your teeth soon afterwards.
Drink fluoridated water.
Don't smoke. Smoking increases your risk for gum disease.

References

HealthyChildren.org [Internet]. Itaska (IL): American Academy of Pediatrics; c2023. What is a Pediatric Dentist?; [updated 2022 Mar 17; cited 2023 Jan 23]; [about 2 screens]. Available from: https://www.healthychildren.org/English/family-life/health-management/pediatric-specialists/Pages/What-is-a-Pediatric-Dentist.aspx
America's Pediatric Dentists [Internet]. Chicago: American Academy of Pediatric Dentists; c2022. Frequently Asked Questions (FAQ); [cited 2023 Jan 24]; [about 3 screens]. Available from: https://www.aapd.org/resources/parent/faq
Centers for Disease Control and Prevention [Internet]. Atlanta: U.S. Department of Health and Human Services; Oral Health; [reviewed 2022 Oct 31; cited 2023 Jan 17]; [about 2 screens]. Available from: https://www.cdc.gov/OralHealth/index.html
Cleveland Clinic: Health Library: Diagnostics & Testing [Internet]. Cleveland (OH): Cleveland Clinic; c2023. Dental Cleaning; [reviewed 2023 Jan 13; cited 2023 Jan 17]; [about 10 screens]. Available from: https://my.clevelandclinic.org/health/treatments/11187-dental-check-up
Cleveland Clinic: Health Library: Diagnostics & Testing [Internet]. Cleveland (OH): Cleveland Clinic; c2023. Oral Hygiene; [reviewed 2022 Apr 21; cited 2023 Jan 17]; [about 10 screens]. Available from: https://my.clevelandclinic.org/health/diseases/16914-oral-hygiene
Cleveland Clinic: Health Library: Diagnostics & Testing [Internet]. Cleveland (OH): Cleveland Clinic; c2023. Sealants; [reviewed 2018 Aug 29; cited 2023 Jan 17]; [about 6 screens]. Available from: https://my.clevelandclinic.org/health/treatments/10912-sealants
Hollingshead CM, Brizuela M. Antibiotic Prophylaxis In Dental and Oral Surgery Practice. [Updated 2022 Nov 2; cited 2023 Jan 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK587360/
Kids Health from Nemours [Internet]. Jacksonville (FL): The Nemours Foundation; c1995-2023. Going to the Dentist; [updated 2020 Aug; cited 2023 Jan 24]; [about 3 screens]. Available from: https://kidshealth.org/en/kids/go-dentist.html
Mayo Clinic [Internet]. Mayo Foundation for Medical Education and Research; c1998-2023. Gingivitis: Symptoms and causes; [cited 2023 Jan 24]; [about 3 screens]. Available from: https://www.mayoclinic.org/diseases-conditions/gingivitis/symptoms-causes/syc-20354453
National Institute of Dental and Craniofacial Research [Internet]. Bethesda (MD): U.S. Department of Health and Human Services; Periodontal (Gum) Disease; [reviewed 2018 Oct; cited 2023 Jan 24]; [about 6 screens]. Available from: https://www.nidcr.nih.gov/health-info/gum-disease/more-info
National Institute of Dental and Craniofacial Research [Internet]. Bethesda (MD): U.S. Department of Health and Human Services; Oral Hygiene [cited 2023 Jan 17]; [about 8 screens]. Available from: https://www.nidcr.nih.gov/health-info/oral-hygiene#related-publications
Radiology Info.org [Internet]. Radiological Society of North America, Inc.; c2023. Panoramic Dental X-ray; [reviewed 2022 Jun 1; cited 2023 Jan 24]; [about 4 screens]. Available from: https://www.radiologyinfo.org/en/info/panoramic-xray
UF Health: University of Florida Health [Internet]. Gainesville (FL): University of Florida Health; c2023. Dental care-adult: Overview; [reviewed 2020 Feb 6; cited 2023 Jan 24]; [about 2 screens]. Available from: https://ufhealth.org/dental-care-adult
UF Health: University of Florida Health [Internet]. Gainesville (FL): University of Florida Health; c2023. Gingivitis: Overview; [reviewed 2020 Feb 6; cited 2023 Jan 24]; [about 2 screens]. Available from: https://ufhealth.org/gingivitis
University of Rochester Medical Center [Internet]. Rochester (NY): University of Rochester Medical Center; c2023. Health Encyclopedia: A Child's First Dental Visit Fact Sheet; [cited 2023 Jan 24]; [about 4 screens]. Available from: https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=1&contentid=1509
UW Health [Internet]. Madison (WI): University of Wisconsin Hospitals and Clinics Authority; c2023. Health Information: Basic Dental Care; [updated 2022 Mar 9; cited 2023 Jan 24]; [about 7 screens]. Available from: https://patient.uwhealth.org/healthwise/article/en-us/hw144414
UW Health [Internet]. Madison (WI): University of Wisconsin Hospitals and Clinics Authority; c2023. Health Information: Dental Checkups for Children and Adults; [updated 2022 Mar 9; cited 2023 Jan 24]; [about 3 screens]. Available from: https://patient.uwhealth.org/healthwise/article/en-us/tc4059
UW Health [Internet]. Madison (WI): University of Wisconsin Hospitals and Clinics Authority; c2023. Health Information: Dental X-Rays;[updated 2022 Mar 9; cited 2023 Jan 24]; [about 4 screens]. Available from: https://patient.uwhealth.org/healthwise/article/en-us/hw211991
WomensHealth.gov [Internet]. Washington DC: Office on Women's Health, U.S. Department of Health and Human Services; Oral Health; [updated 2022 Feb 21; cited 2023 Jan 17]; [about 12 screens]. Available from: https://www.womenshealth.gov/a-z-topics/oral-health