Extraction — erupted tooth note template
A complete, fill-in-the-blank D7140 note written around what insurance reviewers ask for — with the documentation checklist, the denial patterns, and an Open Dental auto-note format built in.
01 · Before you bill it
Know what the payer wants first.
The note should answer every item on the left — and read so that nothing on the right applies.
What documentation D7140 requires
Missing any of these is why the claim pends for records.- A non-restorable diagnosis or a documented patient election after options
- Signed consent naming the site-specific risks
- Hemostasis achieved — the line your lawyer wants
- Written post-op instructions noted as given
- Tooth replacement conversation documented or scheduled
Why D7140 gets denied
The denial patterns payers actually use for this code.- "Extraction" with no diagnosis — the payer can\u2019t see why the tooth came out
- Surgical-level work (sectioning, bone removal, flap) billed as simple D7140 — or the reverse, upcoding without operative detail
- Perio-mobility extractions without a perio chart backing the mobility
02 · The template
Copy it, chart with it.
Square brackets are the blanks — replace each one as you chart. Switch the format to turn every blank into an Open Dental auto-note prompt.
MEDICAL HISTORY: Reviewed [date]; anticoagulants: [none / managed how]. BP [___/___]. DIAGNOSIS: [Tooth #] ([erupted]): [gross caries to pulpal floor / vertical fracture / advanced perio mobility class __] — non-restorable [or not worth restoring per patient election]. OPTIONS: [Endo + crown / extraction / no treatment] reviewed with risks and costs; patient elects extraction. CONSENT: Written consent signed; risks reviewed: [bleeding, dry socket, adjacent restorations, sinus involvement (upper) / nerve involvement (lower)]. ANESTHETIC: [Agent] [__] mL via [technique]. PROCEDURE: [Elevated and delivered with forceps intact / describe]; socket [curetted, irrigated]; [hemostatic agent if used]; hemostasis achieved with pressure. POST-OP: Written and verbal instructions given: [no smoking/straws 72 h; analgesic protocol; salt-water rinses after 24 h]; call criteria reviewed. NEXT VISIT: [Site check / replacement options discussion: implant, bridge, partial].
03 · Common questions
Frequently asked about D7140
When does it become D7210?
Bill an exam the same day?
More templates
Or never fill in a blank again.
Molaris listens to the visit and drafts this exact note in your wording — placeholders already filled from what was actually said. You review, you sign, it files to Open Dental.
Book a 15-minute demo →Reviewed August 2026. These templates are original Molaris reference samples showing how the scribe structures documentation. They are educational examples, not billing, coding, or legal advice; payer requirements vary by plan and state. CDT codes are maintained by the ADA.