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SBSCS | SAUDI BILLING SYSTEM
CODING STANDARDS
Version 3
October 2025
غمان
مجلس الضمان المحي
Council of Health Insurance

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About
Version
Date published
V3
October
2025
The private health insurance market in Saudi Arabia is regulated by the Council of Health Insurance (CHI). To support the market, one of CHI's strategic aims is to provide a standardized code set for billing interventions that providers submit to health insurers. The following is a description of all healthcare services rendered in an ambulatory, secondary, or tertiary environment that shall be coded and billed:
1. Outpatient Medical Services
2. Admitted Care Medical Services
3. Consultation & Rounding Services
4. Dental Services
5. Laboratory & Pathology Services
6. Radiology and Imaging Services
7. Ambulance & Transportation Services
8. Mortuary Services
9. Emergency Medical Services (EMS)
10. Room & Board
SPECIAL ACKNOWLEDGEMENT
Dr. Shabab Al Ghamdi - Secretary General - Council of Health Insurance
PROJECT LEADS
Dr. Wail Yar, CHI
Susan E Young, CHI
Nasser Albuwi, CHI
Fawaz Al Omran, CHI
Faizah Jamalallail, CHI
CONSULTANTS
Heather Grain, SELAT
Anna Coote, SELAT
CONTRIBUTORS
Ahmed Alhamalawy, SELAT
Radi Hamad, SELAT
Safaa S. Eissa, SELAT
Muath AlQasemy, SELAT
Abdulaziz Ibrahim, SELAT
Manal Ali, SELAT
Rawan Faqiri, SELAT
Shahad Almadani, SELAT
Ebtehal Aldokhi, SELAT
Latifah Alrzeen, SELAT
Haytham Ibrahim, SELAT
Ayman Magdi, SELAT
Mohamed AbdelKhalek, SELAT
Ahmed Moustafa, SELAT

Copyright and Disclaimer
© Council of Health Insurance, KSA. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, mechanical, electronic, photocopying, recording, or otherwise, without the prior written permission of the publisher. CHI is a governmental sector registered in the Kingdom of Saudi Arabia CHI Tower King Fahd Rd, Al Malqa, Riyadh 11564
While every reasonable care has been taken to ensure the accuracy of the information within this publication, CHI makes no warranty or guarantee that the information herein is error free and thus will bear no responsibility for the results of the uses of this document.
Address all inquiries to the Council of Health Insurance (cchi-bs@chi.gov.sa)
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Acknowledgment
The Saudi Billing System coding standards (SBSCS) are based on the Australian Consortium for Classification Development (2017) Australian Coding Standards (ACS) for the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) and Australian Classification of Health Interventions (ACHI), both 10 \( ^{th} \) Edition. Sydney: Publisher: Independent Hospital and Aged Care Pricing Authority.

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Table of contents
About....2
Acknowledgment 4
Table of contents 5
GLOSSARY OF TERMS....7
INTRODUCTION....9
SECTION 1 – GENERAL STANDARDS....12
SBSCS 3000 Unlisted codes....12
SBSCS 3010 General guidelines for procedures for non-admitted patients ....14
SBSCS 3011 Bilateral procedures....15
SBSCS 3012 Anaesthesia 16
SECTION 2 – DENTAL SERVICES....18
GENERAL CONVENTIONS FOR DENTAL CODING....18
ORAL MEDICINE AND DIAGNOSIS....20
SBSCS 4000 Examination and diagnostics....20
SBSCS 4001 Diagnostic models....21
PREVENTIVE....22
SBSCS 4005 Preventive procedures ....22
DENTAL ANAESTHESIOLOGY 24
SBSCS 4010 Dental anesthesiology....24
PERIODONTICS....26
SBSCS 4020 Periodontal therapy ....26
SBSCS 4021 Guided tissue regeneration....27
RESTORATIVE....29
SBSCS 4030 Restoration ....29
ENDODONTICS ....31
SBSCS 4040 Pulp capping....31
SBSCS 4041 Pulpotomy ....32
SBSCS 4042 Root canal treatment....32
DENTAL IMPLANTS....36
SBSCS 4050 Intraoral osseointegrated implants....36
SBSCS 4051 Partial dentures implant supported....36
REMOVABLE PROSTHODONTICS ....39
SBSCS 4060 Dentures ....39
SBSCS 4061 Appliances for diagnosed snoring and obstructive sleep apnoea....40
PEDODONTICS ....42
SBSCS 4070 Space maintainer....42
ORTHODONTICS....43
SBSCS 4080 Comprehensive orthodontic exam....43
SBSCS 4081 Sequential plastic aligners....44
ORAL AND MAXILOFACIAL SURGERY....45
SBSCS 4090 Alveolar osseous procedure ....45
SBSCS 4091 Repair of wound....45
SBSCS 4092 Excision of lesion....46
SECTION 3 – IMAGING SERVICES ....47
SBSCS 5000 Imaging procedures for non-admitted care ....47
SBSCS 5020 Digital subtraction angiography and Digital subtraction selective....47
SBSCS 5030 Diagnostic ultrasound of the eye ....50
SECTION 4 – LABORATORY AND PATHOLOGY SERVICES ....51
ESSENTIAL TEST PANELS....51
CLINICAL PATHOLOGY AND URINALYSIS....52
CHEMISTRY....53
SBSCS 6000 Biochemical measurements ....53
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SBSCS 6001 Urinalysis ....53
SBSCS 6002 Drug and chemical toxicology....54
SBSCS 6003 Test panels....55
MICROBIOLOGY....56
SBSCS 6010 Examination & culture procedures....56
SBSCS 6011 Isolation and detection procedures....56
SBSCS 6012 Smears and antimicrobial susceptibility ....57
HAEMATOLOGY....58
SBSCS 6020 Blood and cell count....58
SBSCS 6021 Coagulation....59
SBSCS 6022 Immunology and serology....59
SBSCS 6023 Blood bank....60
MOLECULAR DIAGNOSTICS....61
SBSCS 6030 Genetic testing and sequencing ....61
SBSCS 6031 HLA typing....62
SBSCS 6032 Multianalyte and other molecular assays....63
CLINICAL PATHOLOGY....65
SBSCS 6040 Cytology....65
SBSCS 6041 Histology....66
SBSCS 6042 Cytogenetics....67
SBSCS 6043 In vivo and other pathology procedures....67
ASSISTED REPRODUCTION....69
SBSCS 6050 Female fertility....69
SBSCS 6051 Male fertility....69
SECTION 5 – AMBULANCE AND TRANSPORT SERVICES....71
SBSCS 7000 Emergency road transport....71
SBSCS 7001 Emergency air transport....72
SBSCS 7002 Non-emergency transportation....73
SECTION 6 – EMERGENCY MEDICAL SERVICES....74
SBSCS 8001 Ambulance services....74
SECTION 7 – KSA SERVICE CODES....76
SBSCS 9000 Consultations....76
SBSCS 9010 Telemedicine....77
SBSCS 9011 Homecare services....78
SBSCS 9012 Cardiac catheterization lab....80
SBSCS 9013 COVID-19 packages ....80
SBSCS 9014 Room and board ....82
SBSCS 9015 Room upgrade ....83
SBSCS 9016 Labour and delivery room ....84
SECTION 8 – MORTUARY SERVICES ....85
SBSCS 9050 Mortuary preparation....85
SBSCS 9051 Mortuary transportation....85
SECTION 9 REHABILITATION SERVICES....87
SBSCS 9020 Rehabilitation packages ....87
List of Tables
Table 1: Unlisted codes in SBS V3.0, by SBS chapter 10
Table 2: Tooth numbering system, permanent teeth 14
Table 3: Tooth numbering system, primary teeth 15
Table 4: COVID-19 diagnosis codes 79
Table 5: COVID-19 admitted patient care codes 80
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GLOSSARY OF TERMS
Additional diagnosis: A condition or complaint either co-existing with the principal diagnosis or arising during the episode of admitted patient care, episode of residential care, or attendance at a healthcare establishment.
Note for coding: the additional diagnosis is represented by a code.
Admitted care: services provided to patients who undergo a formal admission process in a hospital
Advanced Life Support:
Acronym: ALS
Advanced life support (ALS) is a set of life-saving techniques and skills that go beyond basic life support (BLS) to help with breathing, circulation, and ventilation. ALS is performed by healthcare providers who have undergone more extensive training.
Ambulatory: See Non-admitted patient service
Basic life support:
Acronym: BLS
An intervention is provided to achieve preliminary preservation or restoration of life.
Clinician: the treating medical officer or person responsible for the patient's care.
Note for coders: A clinician may be a doctor, surgeon, or others responsible for special care, such as midwives, nurses, or allied health professionals.
Note for coders: To assign a code associated with a particular clinician's documentation, the documented information shall be appropriate to the clinician's discipline.
Dental Service:-Non-Inpatient service provided by a dentist or dental specialty unit.
Emergency ambulance service: an ambulance supplier providing immediate care to a Basic Life Support (BLS) or Advanced Life Support (ALS) service in response to an emergency call.
Emergency service:
Acronym: EMS. Ambulance services or paramedic services
Emergency service that provides urgent pre-hospital treatment and stabilisation for illness and injuries and transport to definitive care.
Encounter: single visit to a specific service, including associated diagnostic and procedural services, for example a visit to the Emergency Department, or to a specialist doctor or clinic.
Episode of care: Period of time when a condition is active.
Note for coders: An episode of care includes a period of specific acute disease which might include multiple visits or service events, for example, an episode of care for a fracture could involve initial review in an emergency, surgery to repair the fracture, and ongoing review and diagnostic services to monitor healing.
Home care service: Clinical care provided to a patient virtually or at their place of residence excluding ambulance services
Non-admitted patient service: Services where a patient is not admitted to an acute hospital bed or day stay service.
Not elsewhere classified
Acronym: NEC
An expression used in the context of a warning to classification users that specified variants of the listed procedures or conditions may appear in other parts of the classification.
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Note to coders: Codes including 'NEC' within their description are only to be assigned when the user lacks the information necessary to assign the procedural term to a more specific code.
Not otherwise specified:
Acronym: NOS
Also known as “unspecified” or “unqualified”.
Outpatient Clinic: Organizational arrangement based upon clinical specialties providing appointment-based consultation, procedures, treatment, or other services where there is no hospital bed occupied.
Outpatient clinic service: any examination, consultation, treatment, or other service provided in an outpatient clinic.
Outpatient visit: Interaction between a patient and clinician in an outpatient clinic on a single day and timeslot.
Panel: common group of tests measuring different substances at the same time from one specimen
Principle diagnosis:
For admitted care (inpatient, day case), the principal diagnosis is:
The diagnosis established after the study to be chiefly responsible for occasioning an encounter in:
• admitted patient care, or
• residential care or
• attendance at the health care establishment for a service
For non-admitted care, the principal diagnosis is:
1. The disease, condition or injury which is the reason for the attendance for outpatient treatment or observation
2. The first documented disease, condition or injury (where more than one is documented) which is the reason for attendance for outpatient treatment or observation
Note for coders: Where a complication arises due to treatment in non-admitted care, the Principal Diagnosis is the reason for treatment or observation, with the complication/s coded as Additional Diagnosis/es.
Rehabilitation Program: A group of rehabilitation services provided with a specific goal over a period of time in an ambulatory care environment.
Rehabilitation service: Provision of a therapeutic intervention aimed at improving function.
Note for coding: services may be provided in a rehabilitation program or as a single encounter.
Service provided: healthcare intervention or investigation performed at an encounter or in a program.
Unlisted procedure: services that have not been specifically defined in the current SBS list of codes.
Note for coding: There is a specific set of unlisted codes for various categories of medications as well as one unlisted code for medical devices.
Visit: See Encounter
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INTRODUCTION
The Saudi Billing System includes the following classification standards:
• The International Statistical Classification of Diseases and Related Health Problems, Tenth
• Revision, Australian Modification (ICD-10-AM)
• The Saudi Billing System (SBS) procedure codes
• The Saudi Billing System Coding Standards (SBSCS)
• Australian Coding Standards (ACS)
• The Saudi Food and Drug Authority -GTIN - for Medications and Herbals/Vitamins
• The Saudi Food and Drug Authority -GMDN -for Medical Devices and Consumables.
As of the 1 \( ^{st} \) January 2020, Saudi Arabia mandated the use of the 10th Edition of ICD-10-AM/ACHI/ACS. SBS is built on the Australian classification ICD-10-AM and ACHI, but differs from the Australian system in two ways:
1. New procedure/intervention codes have been added with:
- The addition of a Laboratory and Pathology chapter, an Emergency Services chapter, a Mortuary chapter, a KSA Service Code chapter, a Transport Services chapter, and a Rehabilitation chapter
- Extensive unilateral and bilateral splits.
2. SBS is intended for both admitted and non-admitted care. Non-admitted care includes hospital outpatient visits, office-based specialist physician visits, emergency department visits, home health care, and primary care.
The SBS V3.0 Coding Standards is an update and replacement of the previously released "Standards and Guidelines of CCHI Billing System V2.0", released March 2023 and implemented \(25^{\text{th}}\) January 2024, and shall be used in conjunction with the Australian Coding Standards.
The level of detail in these standards reflects the assumption that users of the document will have had training in abstracting relevant information from clinical records and in the structure of ICD-10-AM and SBS.
The clinical record shall be the primary source of information for the coding of both admitted care and non-admitted cases. If a clinical record is inadequate for complete, accurate coding, the clinical coder shall seek more information from the clinician. A joint effort between the Clinician, Clinical Coder and Clinical Documentation Improvement Specialist is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures.
In the Dental SBS list of codes, the codes are flagged as applicable to either admitted care, non-admitted care, or both.
Basic structure and principles of SBS procedure codes
The Saudi Billing System (SBS) is a modification of the Australian Classification of Health Interventions (ACHI) in ICD-10-AM, 10th edition. The purpose of the SBS is to standardise data for submission of insurance claims and morbidity analysis and mandated reporting. The classification uses a hierarchical structure with the following axes:
■ First level – anatomical site axis
■ Second level – procedure type axis
■ Third level – block axis
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ACHI codes have been modified for the SBS to allow the inclusion of additional codes (including laboratory and pathology, ambulance and transport services, rehabilitation services, service codes or billing services) and further splits on unilateral/ bilateral procedures. SBS retains the same core 7-digit code as ACHI with a two-digit extension where greater specificity has been added to an ACHI code. If there are no modifications to the ACHI code, the two-digit extension will be -00.

Examples of codes without a unilateral/ bilateral extension are as follows:
30195-01-10 Curtettage of lesion of skin, 1 to 14 lesions
30195-01-20 Curetage of lesion of skin, 15 or more lesions
Examples of codes with a unilateral/ bilateral extension are as follows:
55030-00-21 Ophthalmic biometry by ultrasound echography, with intraocular lens power calculation, unilateral
55030-00-22 Ophthalmic biometry by ultrasound echography, with intraocular lens power calculation, bilateral
How to use this document
This document is to be used in conjunction with the Australian Coding Standards (ACS), \(10^{\text{th}}\) Edition. The ACS \(10^{\text{th}}\) Edition standards have been extended in this document to include areas that ACHI does not cover (e.g., laboratory and pathology, ambulance and transport, rehabilitation services, service codes, and mortuary), or to extend the standards to non-admitted services, which are not included in the ACS.
Given that it is a supplement to the ACS, the SBS Coding Standards are only provided for:
- Procedures that are specifically for non-admitted patients (such as many of the dental procedures), OR
- Procedures that apply to admitted and/or non-admitted patients that are not in the ACS (including laboratory and pathology, ambulance and transport services, evaluation and management interventions, emergency medical services, and mortuary services).
Where there are no separate coding standards in this document for procedures that may be classified as admitted or non-admitted, such as dialysis, radiotherapy, and chemotherapy, the standards for non-admitted patients are the same as for same-day admitted patients.
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In this document, the standards are arranged by section. Additional information may be available in the glossary or the introduction.
The term ‘clinician’ is used throughout the document and refers to treating physicians, but may also refer to midwives, nurses, and allied health professionals. In order to assign a code associated with a particular clinician’s documentation, the documented information shall be appropriate to the clinician’s discipline.
SBS V3.0 includes additional codes to those in V2.0, including non-billable codes. Coders shall take care not to miss these additional codes that are required to be coded.
An Appendix A Clinical Explanations has been added to the Tabular List
An Appendix B – Billing Instructions has been added to the Tabular List and applies to SBS Chapters 21 to 26, and Chapter 6.
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SECTION 1 – GENERAL STANDARDS
SBSCS 3000 Unlisted codes
Description
Unlisted codes are reserved for services that have not been defined in the current SBS list of codes (see glossary)
There is a specific set of unlisted codes for various categories of medications as well as one unlisted code for medical devices. For more information regarding these unlisted codes, refer to CHI's Guidelines for Mapping Provider Service Lists to Standard Code Sets
Multiple unlisted codes are available for use in more than one SBS chapter, including:
- Dental
- Imaging services
• Laboratory and pathology
• Ambulance and Transportation services
• KSA Service codes
• No chapter assignment
Rationale
Unlisted codes help expedite and finalize the coding, billing and reimbursement process where an unlisted code is a more accurate representation of the care provided than the term “unspecified”. The unlisted codes are to be used for reporting of specific, known services or procedures for which no other code is applicable. Such procedures or services may result from advances in medical science, including new procedures, new technology, and new devices. Analysis of unlisted codes will aid in identifying areas for future code development or areas in which education and or guidance may be provided where there is an existing code.
Rules
1.1 Use an unlisted code where it is the only option for reporting a service or a procedure.
1.2 Use Unlisted Ambulatory Service code 99999-99-99 only in cases where the performed service description does not match any existing SBS code description and does not fit into any of the other Unlisted Code categories.
1.3 Describe the actual services provided where an unlisted code is submitted on a claim.
1.4 Do not use SBS unlisted codes to report medications or medical devices and consumables.
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Unlisted Codes
Table 1 contains the unlisted codes by SBS chapter and block.
Table 1: Unlisted codes in SBS V3.0, by SBS chapter
<table><tr><td>SBS code</td><td>Long description</td><td>Block</td><td>Block name</td></tr><tr><td colspan="4">Chapter 6: Dental Services</td></tr><tr><td>97089-00-10</td><td>Unlisted oral medicine/ oral pathology procedure</td><td>452</td><td>Other dental diagnostic services</td></tr><tr><td>97179-00-10</td><td>Unlisted preventive dental procedure</td><td>455</td><td>Other preventative dental services</td></tr><tr><td>97399-00-10</td><td>Unlisted oral surgery procedure</td><td>461</td><td>Other dental surgical procedure</td></tr><tr><td>97459-00-10</td><td>Unlisted restorative or endodontic procedure</td><td>464</td><td>Other endodontic service</td></tr><tr><td>97789-00-10</td><td>Unlisted prosthodontic procedure</td><td>477</td><td>Other prosthodontic service</td></tr><tr><td>97879-00-10</td><td>Unlisted orthodontic procedure</td><td>483</td><td>Other orthodontic service</td></tr><tr><td>97989-00-10</td><td>Unlisted adjunctive dental service</td><td>490</td><td>Miscellaneous dental services</td></tr><tr><td colspan="4">Chapter 20: Imaging Services</td></tr><tr><td>99999-99-92</td><td>Unlisted imaging procedure</td><td>2016</td><td>Imaging services</td></tr><tr><td colspan="4">Chapter 21: Laboratory and Pathology</td></tr><tr><td>73050-39-70</td><td>Unlisted chemistry procedure</td><td>2680</td><td>Miscellaneous chemistry testing</td></tr><tr><td>73050-60-60</td><td>Unlisted Immunoassay detection with direct visual observation</td><td>3030</td><td>Immunofluorescent and immunoassay</td></tr><tr><td>73050-61-60</td><td>Unlisted microbiology procedure</td><td>3020</td><td>General, routine, and miscellaneous</td></tr><tr><td>73100-27-21</td><td>Unlisted assay for Virus Antibodies</td><td>3154</td><td>Viral antibody testing</td></tr><tr><td>73100-09-80</td><td>Unlisted Haematology procedure</td><td>3800</td><td>Miscellaneous haematology testing</td></tr><tr><td>73100-18-20</td><td>Unlisted antigen delayed type hypersensitivity (DTH) test</td><td>3801</td><td>Allergy and immunology testing</td></tr><tr><td>73100-22-00</td><td>Unlisted assay for Fungus Antibodies</td><td>3050</td><td>Fungal antibody testing</td></tr><tr><td>73100-25-50</td><td>Unlisted assay for Protozoa Antibodies</td><td>3153</td><td>Parasitic antibody testing</td></tr><tr><td>73150-01-20</td><td>Unlisted urinalysis procedure</td><td>3810</td><td>Urinalysis</td></tr><tr><td>73200-03-60</td><td>Unlisted cytopathology procedure</td><td>4013</td><td>Miscellaneous cytopathology</td></tr><tr><td>73200-06-30</td><td>Unlisted cytogenetic study</td><td>4022</td><td>Cyto9genetics chromosome analysis and interpretation</td></tr><tr><td>73200-10-60</td><td>Unlisted surgical pathology procedure (histo-diagnostic procedure)</td><td>4016</td><td>Surgical pathology and special stains</td></tr><tr><td>73250-03-80</td><td>Unlisted blood bank procedure (transfusion procedure)</td><td>3809</td><td>Special and modified blood products</td></tr><tr><td>73300-03-70</td><td>Unlisted Quantitative Therapeutic Drug Test</td><td>6003</td><td>Miscellaneous drug testing</td></tr><tr><td>73350-06-00</td><td>Unlisted molecular diagnostic procedure</td><td>6055</td><td>General molecular genetic procedure and testing</td></tr><tr><td>73400-00-40</td><td>Unlisted in vivo laboratory procedure</td><td>7006</td><td>Prenatal testing</td></tr><tr><td>73400-01-50</td><td>Unlisted clinical pathology procedure</td><td>7008</td><td>Unlisted reproductive procedures</td></tr><tr><td>73400-05-10</td><td>Unlisted assisted reproduction procedure (male or female)</td><td>7008</td><td>Unlisted reproductive procedures</td></tr><tr><td colspan="4">Chapter 22: Ambulance and transportation services</td></tr><tr><td>83500-00-80</td><td>Unlisted ambulance service</td><td>7009</td><td>Emergency</td></tr><tr><td colspan="4">Chapter 23: KSA Service Codes</td></tr><tr><td>83700-00-00</td><td>Unlisted services yet to be defined</td><td>8012</td><td>Unlisted</td></tr></table>
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SBSCS 3010 General guidelines for procedures for non-admitted patients
Introduction
SBS Coding Standards are provided for procedures that are:
• specifically for non-admitted patients or
- for procedures that apply to admitted and/or non-admitted patients that are not covered by the ACS (laboratory and pathology, ambulance and transport services, evaluation and management interventions, emergency medical services, rehabilitation services, and mortuary services).
Description
In ambulatory settings, a procedure is a medical service or a minor surgical intervention. It includes diagnostic imaging and laboratory tests. It excludes drugs and medical supplies, such as walking aids or dressings.
Rationales
The SBS Coding Standards for procedures for non-admitted patients are different from those for admitted patients because they include procedures that would not normally be coded for admitted patients. Procedures for non-admitted patients are assigned codes because the codes are the basis of billing for the episode of care.
The assignment of codes to an episode of care has financial implications; hence assignment of codes must be based on clear documentation by a clinician.
The hierarchy for coding procedures and services ensures that the procedure/service matches the diagnosis for which it was performed.
Drugs and medical supplies used during a procedure or service are an integral component of the procedure/service and are included in the cost of providing the procedure/service.
Rules
1. Apply the ACS where there are no separate SBS Coding Standards for procedures that may be administered for admitted or non-admitted patients, such as dialysis, radiotherapy, and chemotherapy.
2. For non-admitted patients, SBS Standards take precedence over the ACHI standards.
3. For admitted patients only, ACHI standards apply except for Standards in Chapters 21 - 26.
4. When coding procedures for non-admitted patients, select the procedure or service that accurately describes the service performed. Where documentation is inadequate, the coder shall consult with the clinician before assigning a code.
5. Use the following hierarchy when sequencing the codes for procedures for non-admitted patients:
• Procedure performed for the treatment of the principal diagnosis,
• Procedure performed for treatment of any additional diagnosis,
• Diagnostic/exploratory procedure related to the principal diagnosis,
• Diagnostic/exploratory procedure related to any additional diagnosis.
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6. Assign Chapter 20 procedure codes (which are not coded for admitted patients) for non-admitted patients, for example:
- Doppler recordings,
- X-rays,
• Electromyography,
• Electrocardiography.
7. Assign anaesthesia codes where anaesthesia is used in a non-admitted setting. Include the American Society of Anesthesiologists (ASA) Physical Status Classification code for all anaesthesia codes. See SBSCS 3012
8. Do not assign a code for drugs and medical supplies, such as walking aids or dressings. There are no codes for these physical items. Drugs and medical supplies are coded with GTIN and GMDN codes.
9. The Tabular List of Procedures contains inclusion and exclusion notes, and instructions (see, see also, code also, etc.). These instructions shall be followed, except where the standards in this document overrule these instructions.
Clinical documentation
A service or procedure shall be documented in the clinical record by a clinician before it can be assigned a code.
SBSCS 3011 Bilateral procedures
Description
Bilateral procedures are those which involve the same organ/structure on different sides of the body at the same operative episode.
Note that documentation of "left and right" by a clinician does not always indicate a bilateral organ, for example surgery on "left and right" tongue.
Rules
1. Procedures with separate unilateral/ bilateral codes
SBS provides many separate codes for unilateral/ bilateral procedures where the procedure may be performed on one or both organs/ structures. For example:
• Probing of lacrimal passages,
- Ear toilet,
- Myringotomy,
• Ophthalmological examination,
- Incision of eyelid,
• Magnetic resonance imaging of breast, with contrast medium,
• Radiography of clavicle,
- Removal of intraocular lens.
Where a code is found in the SBS for a unilateral or a bilateral procedure, assign the appropriate code.
2. Inherently bilateral procedures
There are procedures that are 'pseudo-bilateral', which are not explicitly described as bilateral
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in SBS. They include diagnostic or therapeutic interventions which have one entry point but affect bilateral structures, usually vessels, for example, coronary angiography or tonsillectomy.
Where a procedure is inherently bilateral, assign the code once.
3. Procedures with no code option for bilateral
Where a procedure does not have a unilateral/bilateral option, and the procedure is performed bilaterally, assign the code twice.
SBSCS 3012 Anaesthesia
Descriptions
General anaesthesia. 92514-XX-00[1910] General anaesthesia includes intravenous anaesthesia, inhalational anaesthesia or a combination of both.
Sedation The distinction between sedation and general anaesthesia is often unclear from clinical documentation. For the purposes of classification, code 92515-XX-00 [1910] Sedation may be assigned where the anaesthetic is administered as per general anaesthesia (i.e. intravenous or inhalational or both) and there is no documentation of the use of an artificial airway, such as an endotracheal tube, laryngeal mask (e.g. LM3, LMA4), pharyngeal mask (e.g. PM3) or Guedel airway.
Local anaesthesia. 92513-XX-00 [1909] Infiltration of local anaesthetic is assigned for administration of local anaesthetic, where the effect of the anaesthesia is at localised tissue level.
ASA scores. Based on the American Society of Anesthesiologists (ASA) Physical Status Classification, coding anaesthesia requires a two-character extension to the 5-digit code which represents the patient's ASA score.
Table 2: Anaesthesia status
First character:
<table><tr><td>ASA class</td><td>Description</td></tr><tr><td>1</td><td>A normal healthy patient</td></tr><tr><td>2</td><td>A patient with mild systemic disease</td></tr><tr><td>3</td><td>Patient with severe systemic disease that limits activity</td></tr><tr><td>4</td><td>Patient with severe systemic disease that is a constant threat to life</td></tr><tr><td>5</td><td>A moribund patient who is not expected to survive longer than 24 hours without surgical intervention</td></tr><tr><td>6</td><td>A declared brain-dead patient whose organs are being removed for donor purposes</td></tr><tr><td>9</td><td>No documentation of ASA score</td></tr></table>
Second character:
<table><tr><td>Emergency modifier</td><td>Character</td><td>Description</td></tr><tr><td>E</td><td>0</td><td>Procedure being performed as an emergency</td></tr><tr><td></td><td>9</td><td>Nonemergency or not known</td></tr></table>
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Rules
1. For non-admitted patients, all anaesthesia is coded.
2. Assign the code once for each different anaesthetic used for each encounter, including General anaesthesia or sedation, local anaesthesia, regional nerve blocks and. neuraxial blocks.
3. Assign an ASA code for each type of anaesthesia.
4. Where there is no documentation of ASA score or the emergency modifier is not indicated, filler digits of '9' shall be assigned for the \( 6^{th} \) and \( 7^{th} \) digits.
5. The \( 8^{th} \) and \( 9^{th} \) digits for anaesthesia shall be -00
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SECTION 2 – DENTAL SERVICES
In this section, general conventions applicable to Dental services (SBS Chapter 6) are included, followed by dental specialty standards.
GENERAL CONVENTIONS FOR DENTAL CODING
Code the problem as a primary diagnosis if known. If the diagnosis is not known, then code the symptom as a principal diagnosis.
When a procedure has been discontinued for any reason before completion, the assigned code shall indicate the stage at which the procedure was stopped, and a code for discontinued service shall be assigned to provide an opportunity for the procedure to be repeated if medically necessary.
The tooth number(s) shall be recorded with every dental procedure where applicable. Tooth number shall be documented by the clinician in HIS/EMR and interfaced for the claims submission to NPHIES.
Notes on tooth numbering are listed in this section for easy reference, as they apply to all dental subspecialties.
Table 2: Tooth numbering system, permanent teeth
<table><tr><td>11 Upper right permanent central incisor</td><td>31 Lower left permanent central incisor</td></tr><tr><td>12 Upper right permanent lateral incisor</td><td>32 Lower left permanent lateral incisor</td></tr><tr><td>13 Upper right permanent canine</td><td>33 Lower left permanent canine</td></tr><tr><td>14 Upper right permanent 1st premolar</td><td>34 Lower left permanent 1st premolar</td></tr><tr><td>15 Upper right permanent 2nd premolar</td><td>35 Lower left permanent 2nd premolar</td></tr><tr><td>16 Upper right permanent 1st molar</td><td>36 Lower left permanent 1st molar</td></tr><tr><td>17 Upper right permanent 2nd molar</td><td>37 Lower left permanent 2nd molar</td></tr><tr><td>18 Upper right permanent 3rd molar</td><td>38 Lower left permanent 3rd molar</td></tr><tr><td>21 Upper left permanent central incisor</td><td>41 Lower right permanent central incisor</td></tr><tr><td>22 Upper left permanent lateral incisor</td><td>42 Lower right permanent lateral incisor</td></tr><tr><td>23 Upper left permanent canine</td><td>43 Lower right permanent canine</td></tr><tr><td>24 Upper left permanent 1st premolar</td><td>44 Lower right permanent 1st premolar</td></tr><tr><td>25 Upper left permanent 2nd premolar</td><td>45 Lower right permanent 2nd premolar</td></tr><tr><td>26 Upper left permanent 1st molar</td><td>46 Lower right permanent 1st molar</td></tr><tr><td>27 Upper left permanent 2nd molar</td><td>47 Lower right permanent 2nd molar</td></tr><tr><td>28 Upper left permanent 3rd molar</td><td>48 Lower right permanent 3rd molar</td></tr></table>
Table 3: Tooth numbering system, primary teeth
<table><tr><td>51 Upper right primary central incisor</td><td>71 Lower left primary central incisor</td></tr><tr><td>52 Upper right primary lateral incisor</td><td>72 Lower left primary lateral incisor</td></tr><tr><td>53 Upper right primary canine</td><td>73 Lower left primary canine</td></tr><tr><td>54 Upper right primary first molars</td><td>74 Lower left primary first molar</td></tr><tr><td>55 Upper right primary second molars</td><td>75 Lower left primary second molar</td></tr><tr><td>61 Upper left primary central incisor</td><td>81 Lower right primary central incisor</td></tr><tr><td>62 Upper left primary lateral incisor</td><td>82 Lower right primary lateral incisor</td></tr><tr><td>63 Upper left primary canine</td><td>83 Lower right primary canine</td></tr><tr><td>64 Upper left primary first molars</td><td>84 Lower right primary first molars</td></tr><tr><td>65 Upper left primary second molars</td><td>85 Lower right primary second molars</td></tr></table>
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Figure 1: Numbering system FDI for adults and children

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ORAL MEDICINE AND DIAGNOSIS
SBSCS 4000 Examination and diagnostics
Description
A dental exam is an examination of teeth, gums and surrounding hard and soft tissue. Depending on the type of exam provided, examinations can be divided as follows:
• Comprehensive oral examination
Includes a complete inspection of oral mucosa, hard and soft tissue, salivary glands and all structures present in the oral cavity.
• Comprehensive examination and risk assessment of head and neck by a dental surgeon
Includes a comprehensive examination and assessment of the head and neck's extraoral and intraoral tissues used for the detection and diagnosis of any disease or tissue abnormality.
This may aid in the detection of early indications of oral or tonsillar cancer, allowing for prompt diagnosis and treatment.
• Periodic oral examination
Comprehensive or limited oral cavity examinations are done on a periodic basis (e.g., once in 6 months or a year).
• Limited oral examination
A single tooth (crown, root, periodontal ligament) examination or examination of a region or affected tooth, gums, tongue, oral mucosa, palate, periodontal structures, alveolar bone, the floor of the mouth, or any other region limited to the definition of oral cavity.
• Oral examination; post operative re-evaluation
Post-operative examination is initiated after suture removal or any complications related to the surgery.
- New patient
A new dental patient is one who attends for treatment for a condition that has not previously been diagnosed with or treated during the current episode of care.
- Repeat patient.
A repeat dental patient is one who attends for continuation of an episode of care.
Rationale
It is important to recognize the reason for the dental visit to assign the most appropriate code. For the first dental visit, most patients will need a full mouth examination to assess the oral health state and determine the final treatment plan.
Rules
1. New patients for a full mouth examination: Assign code 97011-00-00 [450] Comprehensive oral examination.
2. 97012-00-00 [450] Periodic oral examination shall only be assigned if the dentist has met the patient earlier, or the patient has previously been scheduled for a later visit. Otherwise, it shall be coded as Comprehensive or Limited based on definition.
3. For emergency visits or visits where the patient has a chief complaint, where the dentist is
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only focused on treating the problem area - assign 97013-00-00 [450] limited oral examination.
4. 97011-00-10 [450] Oral examination; post operative re-evaluation, shall be assigned when the dentist's examination is only focused on examining a previously treated area (e.g., for suture removal, or any complications related to the surgery).
Example:
A 14-year-old patient came to the clinic for the first time, clinical examination revealed good oral health.
Z01.2
Dental examination
97011-00-00 [450]
Comprehensive oral examination
SBSCS 4001 Diagnostic models
Description
Diagnostic models, also known as diagnostic casts or study models, are typically used to study the patient's jaw relation. They are useful in determining the patient's final treatment plan. Casts can be traditionally fabricated (using plaster or other materials) or digitally fabricated.
Rules
1. 97071-00-00 [452] Preparation of dental diagnostic cast is assigned for the production of a model from an impression or digital data. This code covers taking the impression and the model fabrication. It does not cover the bite registration or the mounting of the model.
2. 97964-00-00 [489] Registration and mounting of model for occlusal analysis is assigned where the cast or model is being used for occlusal analysis or for the fabrication of indirect tooth restoration (e.g., inlays, crowns, fixed and removal dentures, etc.).
Example:
A patient came to the dental clinic. Clinical examination revealed excessive wear and loss of vertical dimension of occlusion. Impression was taken and a diagnostic cast was fabricated to assess occlusal relation. Assign and sequence as:
Z01.2 Dental examination
97011-00-00 [450] Comprehensive oral examination
97071-00-00 [452] Preparation of dental diagnostic cast
97964-00-00 [489] Registration and mounting of model for occlusal analysis
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PREVENTIVE
SBSCS 4005 Preventive procedures
Introduction
Preventive dentistry can help identify problems early in children's lives before dental problems become worse or require more invasive interventions. They can also identify dental problems in adults. Services typically include promoting good dental habits, including brushing and flossing, guidance minimizing or avoiding thumb sucking, and advice on eating habits that help improve dental health. Regular teeth cleanings and oral exams usually performed every 6 months. Routine X-rays may be taken as well to help track jaw and teeth development.
Descriptions
Remineralization and cariostatic agents
The remineralization process is a natural repair mechanism to restore the minerals to the tooth. It occurs when calcium and phosphate mineral ions are redeposited within the demineralized lesion from saliva, resulting in the formation of a surface more resistant to acid dissolution. Re-mineralising agents can be broadly classified into fluorides and non-fluoride re-mineralising agents. The modes of delivery of remineralising agents may be dentifrices, mouth rinses, lozenges or chewing gum (Example 1).
Bleaching
The main goal of tooth bleaching or whitening is to restore the tooth's natural shine and whiteness which have diminished over time with exposure to factors that cause discoloration. It can be performed in the office (both externally and internally) or at home (externally) (Example 2).
Administration of pharmacological agent
Pharmacological agents can be administered for therapeutic reasons or to aid in dental treatment. Therapeutic drugs include antiseptics, steroids, analgesics, antimicrobials, or antifungals. Example of these agents can be administered in many routes, such as intra-arterial, enteral, intracavitary, intramuscular, intrathecal, or intravenous (Example 3).
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Rationale
Fluoride is effective in protecting against tooth decay and in repairing early lesions in the teeth that can turn into cavities. As such, it is usually used as a prevention method. In some cases, it may be indicated to use mineralization substances into a carious enamel surface to interrupt the carious process and aid in the remineralization process.
Rules
1. Clear documentation of the mode of administration of preventative measure is needed to assign the appropriate code. The code shall be assigned once in the episode of care regardless of the number of times administered.
2. In cases where the same pharmacological agent is being administered in different entry routes, different codes shall be assigned to reflect the specific administration route used.
3. In cases where multiple pharmacological agents are administered, codes shall be added to reflect the different agents used.
Example 1:
A 7-year-old patient came to the clinic for a periodic check-up. Examination showed good oral health. The dentist performed a topical application of fluoride as part of a preventive program. Assign and sequence as:
Z01.2 Dental examination
97012-00-00 [450] Periodic oral examination
97121-01-00 [454] Topical application of remineralisation agent, 1 treatment
Example 2:
18-year-old female patient came to the clinic for a periodic oral evaluation. Her radiographic images are up to date, and she is interested in at-home teeth whitening as her teeth were discoloured.
K03.6 Deposits [accretions] on teeth
97012-00-00 [450] Periodic oral examination
97119-00-00 [453] Bleaching, home application, per arch
97926-00-00 [485] Fabrication of mandibular or maxillary tray for self-application of medicament
Example 3:
52-year-old male patient previously diagnosed with prostate cancer was admitted for same-day chemotherapy. Intravenous (IV) cyclophosphamide was given and the patient was discharged same-day.
Z51.1 Pharmacotherapy session for neoplasm
C61 Malignant neoplasm of prostate
M8000/3 Neoplasm, malignant
96199-00-00 [1920] Intravenous administration of pharmacological agent, antineoplastic
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DENTAL ANAESTHESIOLOGY
SBSCS 4010 Dental anesthesiology
Introduction
Several techniques can be used to administer anesthesia in the dental field. Some dental procedures are performed using one anaesthesia method, while others may be performed using a combination of two or more techniques.
The amount of anaesthesia used shall be recorded for documentation purposes. However, the codes used can only be reimbursed once regardless of the amount of anaesthesia used.
Descriptions
General anaesthesia. Dental treatment under general anaesthesia is reserved for patients whose behaviour cannot be managed by non-pharmacological (e.g., tell-show-do, positive reinforcement, voice control, distraction) or pharmacological (nitrous oxide sedation, oral sedation) techniques.
Sedation is the reduction of irritability or anxiety by administration of sedative drugs, generally to facilitate a medical, dental or diagnostic procedure. Examples of drugs which can be used for sedation include isoflurane, diethyl-ether, propofol, etomidate, ketamine, pentobarbital, lorazepam and midazolam. Sedation methods in dentistry include inhalation sedation (using nitrous oxide), and intravenous (IV, cerebral) sedation.
Local anaesthesia. Several techniques can be used to achieve local anaesthesia of the dentition and the surrounding hard and soft tissues of the maxilla and mandible. There are three main anaesthetic agents that can be used, Lidocaine, Bupivacaine, and Mepivacaine. The type of procedure to be performed as well as the location of the procedure determine the technique of anaesthesia to be used, such as:
- Infiltration: The local infiltration technique anesthetizes the terminal nerve endings of the dental plexus. This technique is indicated when an individual tooth or a specific isolated area requires anaesthesia. The procedure is performed within the direct vicinity of the site of infiltration.
■ Nerve block, trigeminal & Regional block, nerve of head or neck. The nerve block anesthetizes the main branch of a specific nerve other than trigeminal nerve division, allowing treatment to be performed in the region innervated by that nerve.
ASA scores. Based on the American Society of Anesthesiologists (ASA) Physical Status Classification, coding anaesthesia requires a two-character extension which represents the patient's ASA score (see SBSCS 3012).
Rules
1. Assign the code once for each different anaesthetic used for each encounter.
2. Where both sedation and local anaesthesia are administered, assign a code for both.
3. Where other types of anaesthesia are used (e.g., infiltration, nerve blocks) they shall be coded separately.
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4. Assign an ASA code for each type of anaesthesia.
5. Where there is no documentation of ASA score or the emergency modifier is not indicated, filler digits of '9' shall be assigned.
Example 1:
A patient came to the clinic for surgical extraction of partially impacted wisdom tooth #38. The patient was anxious and was put under sedation for 45 minutes. The procedure was performed under local anaesthesia, inferior alveolar nerve block. Assign and sequence as:
K01.1 Impacted teeth
97321-01-00 [458] Surgical removal of impacted tooth; partial bony impacted tooth; per tooth
92509-99-10 [1909] Administration of anaesthesia, trigeminal division block, regional block, nerve of head or neck, ASA 99
92515-99-00 [1910] Sedation, ASA 99
Example 2:
A patient came to the clinic for the extraction of a non-restorable tooth #36. Nerve block was administered, and surgical extraction of the tooth was performed. Assign and sequence as:
K01.1 Impacted teeth
97321-05-00 [458] Surgical removal of one tooth; soft tissue (not requiring removal of bone or tooth division)
92509-99-10 [1909] Administration of anaesthesia, trigeminal division block, regional block, nerve of head or neck, ASA 99
Example 3:
62 years old male, diagnosed with pleomorphic adenoma, is admitted for total excision of parotid gland with preservation of the facial nerve. The patient has an increased risk for complications from a general anaesthesia. The procedure was performed under local or regional anaesthesia. ASA score is 3. Assign and sequence as:
D11.0 Benign neoplasm of Parotid gland
M8940/0 Pleomorphic adenoma
30250-00-00 [397] Total excision of parotid gland with preservation of facial nerve
92509-39-00 [1909] Regional block, nerve of head or neck, ASA 39
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PERIODONTICS
SBSCS 4020 Periodontal therapy
Introduction
Periodontal diseases may be treated conservatively (non-surgically) using periodontal therapy. It aims to monitor and control periodontal conditions, without surgical interventions. Ultimately, it promotes periodontal health, preventing tooth loss.
Descriptions
Periodontal scaling and root planning consists of the removal of plaque, calculus and stains from supragingival and subgingival tooth surfaces. Root planning is the removal of cementum and dentine that is rough and/or permeated by calculus.
Periodontal maintenance visit is scheduled following periodontal therapy. It constitutes a full mouth re-evaluation and removal of plaque, supragingival and subgingival calculus and teeth polishing. However, if new or recurring periodontal disease appears then additional diagnoses and treatment shall be coded.
Periodontal surgery may occasionally be required to treat some gum diseases and disorders, such as gingivitis or periodontitis. The operation is intended to address periodontal disease and any harm it may have done by repair of harmed tissues and bones. These procedures include:
■ Periodontal flaps
A periodontal flap is a section of gingiva, mucosa, or both that is surgically separated from the underlying tissues to provide for the visibility of and access to the bone and root surface. The flap also allows the gingiva to be displaced to a different location in patients with mucogingival involvement.
Periodontal flaps can be classified based on the flap position after the surgery as:
○ Non-displaced flaps
Non-displaced flaps include periodontal flaps that are usually performed to gain better access for scaling and root planning, (e.g., periodontal flaps, flaps used for curettage) or for crown lengthening procedures.
○ Displaced flaps
Displaced flaps include rotational and transposition flaps. A rotation flap is a semi-circular flap of skin and subcutaneous tissue that rotates about a pivot point into a defect. The donor site is typically repaired with wide undermining and direct, layered closure. The vector of greatest tension is directed from the pivot point outward to the defect's furthest radial point. Transposition flaps are generally smaller in size than advancement and rotation flaps. Transposition flaps, like all flaps, utilize tissue adjacent to the wound for reconstruction, generally offer a good colour and textural match.
Rationale
Periodontal scaling and root planning procedure can be performed in one visit or up to four visits. Special care shall be taken with regard to the visit or encounter number to assign the appropriate code.
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Assigning a code for periodontal flap procedure depends either on the flap position after surgery, or on the number of teeth, or the area treated.
Rules
1. For the first visit for an episode of care to this dental clinic, assign 97281-00-10 [456] Generalized scaling and root planning; severe plaque and calculus deposition, first appointment.
2. For subsequent visits assign 97115-00-00 [453] Removal of calculus from surfaces of teeth – subsequent appointment.
3. When a flap procedure is being performed on multiple teeth in one quadrant, assign 97232-00-10 [456] Periodontal flap procedure, per quadrant.
4. . When open flap procedure is recorded assign 97271-01-00 [456] Open flap or curettage surgery; per tooth or implant.
5. Only assign 97238-00-10 [456] Periodontal flap procedure for crown lengthening, per tooth when the reason for the procedure (crown lengthening) is documented.
Example:
A patient came to the clinic presenting with inflamed gingival tissue around an implant replacing tooth #26, bleeding upon probing, and deep pocket depths (4mm). Scaling and debridement as treatment for inflammation of an implant were done. Open flap procedure was also done. Assign and sequence as:
<table><tr><td>K05.5</td><td>Other periodontal disease</td></tr><tr><td>97271-01-00 [456]</td><td>Open flap or curettage surgery; per tooth or implant</td></tr><tr><td>97281-00-60 [456]</td><td>Scaling and debridement in the presence of inflammation or mucositis of an implant, including cleaning of the implant surfaces, without flap entry and closure; per implant</td></tr></table>
SBSCS 4021 Guided tissue regeneration
Descriptions
Guided tissue regeneration is a surgical procedure that specifically aims to regenerate the periodontal tissues when the periodontal disease is advanced. It is a method used to repair periodontal defects so that a tooth, or set of teeth, has more support and stability. In addition to this procedure a resorbable or non-resorbable artificial membrane may be used to aid in the osseous regeneration.
Non-resorbable membranes are bio-inert and require a second surgical procedure to remove them after bone regeneration is complete.
Resorbable membranes are naturally biodegradable and have varying resorption rates.
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Rules
1. Tissue regeneration does not include flap entry and closure, and shall be coded separately when documented.
2. If documented, a separate code shall be assigned for resorbable membrane procedure
Example 1:
A patient came to the clinic with erythema, throbbing and radiating pain, and swelling of the gingiva over teeth #36 and #37. Examination showed tooth mobility. The patient was diagnosed with Acute periodontitis and incision and drainage of the abscess were performed. Assign and sequence as:
K05.2 Acute periodontitis
97213-00-00 [456] Treatment of acute periodontal infection
Example 2:
A patient came to the clinic with pain and swelling of the gingiva over teeth #33 and #34. Examination showed tooth mobility. The patient was diagnosed with Acute apical periodontitis related to tooth# 33. An endodontic treatment of the tooth was performed:
K04.4 Acute apical periodontitis of pulpal origin
97420-01-00 [462] Root canal treatment, anterior (includes extirpation of pulp, chemomechanical preparation, obturation)
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RESTORATIVE
SBSCS 4030 Restoration
Introduction
Dental restoration, dental fillings, or simply fillings are treatments used to restore the function, integrity, and morphology of missing tooth structure resulting from caries or external trauma.
Dental restorative materials that are used for filling tooth cavities or treating dental caries are classified into four categories: amalgam, resin-based composites, glass ionomer, and resin-modified glass ionomer.
Descriptions
The tooth contains 4 layers from outside to inside:
First layer Enamel (crown),
Second layer cementum (root),
Third layer (dentine)
Fourth layer (pulp).
Rules
1. When coding restorative treatment operative procedures, the extent of caries needs to be identified assign:
■ K02.0 Caries limited to enamel or,
■ K02.1 Caries of dentine or,
■ K02.2 Caries of cementum or,
■ K02 Caries with pulp exposure,
and assign only one code for the deepest layer.
2. Dental restoration starts with excavation of caries, etching, and bonding, and then dental restoration is applied. All four steps are included in one SBS procedure code.
3. In the case of one surface restoration, assign
■ 97521-01-00 [466] Adhesive restoration (e.g., compomer, composite, glass ionomer, polymer glass, resin composite), 1 surface, direct or
■ 97511-01-00 [465] Metallic restoration of tooth, 1 surface, direct, based on the material used for restoration.
4. For each additional surface, assign
■ 97521-02-00 [466] Adhesive restoration (e.g., compomer, composite, glass ionomer, polymer glass, resin composite), each additional surface, direct or
■
7511-02-00 [465] Metallic restoration of tooth, each additional surface, direct, according to the number of surfaces and material used.
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Example:
Basic oral evaluation history: A patient who had not been seen by the clinic before did not report any complaints, but requested a “complete dental check-up”.
The doctor performed a complete head and neck exam, including both extra and intra-oral soft and hard tissues, evaluated the TMD and found that lymph nodes were within normal limits. An orthopantomogram and 4 bitewing radiographs were taken, then positive findings appeared on the bitewing, the patient has class II in tooth #15. Caries excavated up to dentine; etching, and bonding were performed followed by a final restoration for a three surfaces resin composite for premolar followed by finishing and polishing the restoration. Assign and sequence as:
Z01.2 Dental examination
K02.1 Caries of dentine
97011-00-00 [450] Comprehensive oral examination
57960-00-00 [1967] Orthopantomography
97022-00-20 [451] x 4 Intraoral bitewing radiography, per exposure
97521-01-10 [466] Adhesive restoration (e.g., compomer, composite glass ionomer, polymer glass, resin composite), 1 surface, direct
97521-02-00 [466] x 2 Adhesive restoration (e.g., compomer, composite, glass ionomer, polymer glass, resin composite), each additional surface, direct
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ENDODONTICS
SBSCS 4040 Pulp capping
Descriptions
Two different types of pulp capping are in use. These methods are used when the pulp is visibly exposed (vital pulp exposure) due to caries, trauma, or iatrogenic insults such as accidental exposure during tooth preparation or caries removal.
In direct pulp capping, the protective dressing is placed directly over an exposed pulp
In indirect pulp capping, a thin layer of softened dentin, which, if removed, would expose the pulp, is left in place, and the protective dressing is placed on top.
Rule
1. Assign SBS code
■ 97411-00-10 [462] Direct pulp capping or
■ 97411-01-00 [462] Indirect pulp capping appropriately and
■ ICD-10 code K02 Caries with pulp exposure.
Example:
A 16-year-old male patient scheduled for routine dental treatment, reported discomfort associated with physical stimulation on the permanent mandibular left first molar. No history of spontaneous pulpal pain was reported. The status of the pulp and periradicular tissues were carefully evaluated.
The clinical examination revealed a normal appearance of adjacent gingival tissue and a small enamel caries lesion. A slight colour change was noticed through occlusal enamel. Bitewing radiograph revealed a deep distal caries lesion. No radiolucency at the periapical regions or thickness of the periodontal spaces were noticed in periapical radiograph. Pulp sensitivity compatible with a reversible stage of inflammation was confirmed with thermal tests. The pain quickly disappeared after the cold stimulus.
Assign and sequence code as follows:
First visit:
Z01.2 Dental examination
K02 Caries with pulp exposure
97013-00-00 [450] Limited oral examination
97022-00-20 [451] Intraoral bitewing radiography, per exposure
97411-01-00 [462] Indirect pulp capping
Second visit after 60 days:
97022-00-20 [451] Intraoral bitewing radiography, per exposure
97521-01-10 [466] Adhesive restoration (e.g., compomer, composite, glass ionomer, polymer glass, resin composite), 1 surface, direct
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SBSCS 4041 Pulpotomy
Descriptions
• Pulpotomy for immature permanent dentition
An immature permanent tooth is a young/newly erupted permanent tooth with incomplete root apex formation. After a permanent tooth emerges in the mouth, it usually takes three more years for the root development to complete.
The treatment for immature permanent teeth with pulp exposure due to caries or trauma gives evidence of extensive coronal pulpitis and also requires an emergency procedure for permanent mature teeth until root canal treatment can be accomplished.
• Pulpotomy for primary dentition
A pulpotomy is performed in a primary tooth when caries removal results in a pulp exposure in a tooth with a normal pulp or reversible pulpitis or after a traumatic pulp exposure and there is no radiographic sign of infection or pathological resorption
• Partial pulpotomy
Partial pulpotomy, rather than direct pulp capping or complete pulpotomy, is the treatment of choice following traumatic or carious pulp exposure in immature permanent teeth

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