Welcome » May 13, 2024 11:23 AM

Program Name:	BadgerCare Plus and Medicaid	Handbook Area:	Dental
05/13/2024

Covered and Noncovered Services : Codes

Topic #6717

Administration Procedure Codes for Physician-Administered Drugs

For physician-administered drugs administered to members enrolled in BadgerCare Plus HMOs, Medicaid SSI HMOs, and most special MCOs, all CPT administration procedure codes should be indicated on claims submitted for reimbursement to the member's MCO.

Topic #2806

Area of Oral Cavity Codes

BadgerCare Plus has identified allowable areas of oral cavity codes for dental services providers.

Note: BadgerCare Plus does not require an area of oral cavity code for all dental services.

Area of Oral Cavity Code	Description
01	Maxillary
02	Mandibular
10	Upper right quadrant
20	Upper left quadrant
30	Lower left quadrant
40	Lower right quadrant

Topic #2808

BadgerCare Plus/Medicaid Diagnostic, Preventive, Restorative, Endodontics, Periodontics, General Codes

The following procedure codes are reimbursed under BadgerCare Plus and Medicaid.

D0100–D0999 Diagnostic

Covered diagnostic services are identified by the allowable CDT procedure codes listed in the following tables. Reimbursement is allowable only for services that meet all program requirements. This includes documenting the medical necessity of services in the member's medical record. Providers should not bill for radiographs/diagnostic imaging (interpretation only) in combination with global codes.

Code	Description of Service	Prior Authorization?	Limitations and Requirements
Clinical Oral Examinations
D0120	Periodic oral evaluation — established patient	No	One per six-month period, per member, per provider. (Also billable for teledentistry.)
D0140	Limited oral evaluation — problem focused	No	One per six months, per member, per provider. (Also billable for teledentistry.)
D0150	Comprehensive oral evaluation — new or established patient	No	One per three years, per member, per provider.
D0160	Detailed and extensive oral evaluation — problem focused, by report	No	One per three years, per member, per provider.
D0170	Re-evaluation — limited, problem focused (established patient; not post-operative visit)	No	Allowed once per year, per member, per provider. Allowable in office or hospital POS. (Also billable for teledentistry.)
D0191	Assessment of a patient	No	One per six months, per member, per provider. Code billable only by dental hygienists.(Also billable for teledentistry.)
Radiographs/Diagnostic Imaging (Image Capture With Interpretation)
D0210	Intraoral — complete series of radiographic image	No³	One per three years, per member, per provider. Not billable within six months of other X-rays including D0220, D0230, D0240, D0270, D0272, D0274, and D0330 except in an emergency.¹ Panorex plus bitewings may be billed under D0210.
D0220	Intraoral — periapical first radiographic image	No	One per day. Not payable with D0210 on same DOS or up to six months after.²
D0230	Intraoral — periapical each additional radiographic image	No	Up to three per day. Must be billed with D0220. Not payable with D0210 on same DOS or up to six months after.²
D0240	Intraoral — occlusal radiographic image	No	Up to two per day. Not payable with D0210 on same DOS.
D0250	Extra-oral — 2D projection radiographic image created using a stationary radiation source, detector	No	Emergency only, one per day.¹
D0251	Extra-oral posterior dental radiographic image	No	Not payable with D0210, D0270, D0272, D0273, or D0274 on same DOS or up to six months after.²
D0270	Bitewing — single radiographic image	No	One per day, up to two per six-month period, per member, per provider. Not payable with D0210, D0272, D0273, or D0274 on same DOS or up to six months after.²
D0272	Bitewings — two radiographic images	No	One set of bitewings per six-month period, per member, per provider. Not payable with D0210, D0270, D0273, or D0274 on same DOS or up to six months after.²
D0273	Bitewings — three radiographic images	No	One set of bitewings per six-month period, per member, per provider. Not payable with D0210, D0270, D0272, or D0274 on same DOS or up to six months after.²
D0274	Bitewings — four radiographic images	No	One set of bitewings per six-month period, per member, per provider. Not payable with D0210, D0270, D0272, or D0273 on same DOS or up to six months after.²
D0277	Vertical bitewings — 7 to 8 radiographic images	No	Only for adults aged 21 and older once per 12 months. Not payable with any other bitewings on the same DOS.
D0330	Panoramic radiographic image	No³	One per day when another radiograph is insufficient for proper diagnosis. Not payable with D0210, D0270, D0272, D0273, or D0274.
D0340	2D cephalometric radiographic image — acquisition, measurement and analysis	No	Orthodontia diagnosis only. Allowable for members up to age 20.
D0350	2D oral/facial photographic image obtained intra-orally or extra-orally	No	Allowable for members up to age 20. Allowable for orthodontia or oral surgery.
D0372	Intraoral tomosynthesis — comprehensive series of radiographic images	No	One per three years, per member, per provider.
D0373	Intraoral tomosynthesis — bitewing radiographic image	No	One per three years, per member, per provider.
D0374	Intraoral tomosynthesis — periapical radiographic image	No	One per three years, per member, per provider.
Radiographs/Diagnostic Imaging (Interpretation Only)
D0391	Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report	No	The number of images interpreted should be billed as units.
Radiographs/Diagnostic Imaging (Image Capture Only)
D0387	Intraoral tomosynthesis — comprehensive series of radiographic images — image capture only	No	One per day when another radiograph is insufficient for proper diagnosis.
D0388	Intraoral tomosynthesis — bitewing radiographic image — image capture only	No	One per day when another radiograph is insufficient for proper diagnosis.
D0389	Intraoral tomosynthesis — periapical radiographic image — image capture only	No	One per day when another radiograph is insufficient for proper diagnosis.
D0701	Panoramic radiographic image — image capture only	No	One per day when another radiograph is insufficient for proper diagnosis. Not payable with D0708 or D0709.
D0702	2–D cephalometric radiographic image — image capture only	No	Orthodontia or oral surgery diagnosis only.
D0703	2–D oral/facial photographic image obtained intra orally or extra orally — image capture only	No	Allowable for all dental procedures and all dental specialties, including general dentists.
D0705	Extra-oral posterior dental radiographic image — image capture only	No	Not payable with D0708 or D0709 on same DOS or up to six months after.
D0706	Intraoral — occlusal radiographic image — image capture only	No	Up to two per day. Not payable with D0709 on same DOS.
D0707	Intraoral — perapical radiographic image — image capture only	No	Up to four per DOS. Not payable with D0709 on same DOS or up to six months after.
D0708	Intraoral — bitewing radiographic image — image capture only	No	One set of bitewings per six month period, per member, per provider. Not payable with D0709 on same DOS or up to six months after.
D0709	Intraoral — complete series of radiographic images — image capture only	No	One per three years, per member, per provider. Not billable within six months of other X-rays including D0701, D0706, D0707, and D0708, except in an emergency. Panorex plus bitewings image capture only may be billed under D0709.
Tests and Examinations
D0470	Diagnostic casts	No	Orthodontia diagnosis only. Allowed with PA for members ages 21 and over, at BadgerCare Plus's request (for example, for dentures).
D0486	Laboratory accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written report	No	None.
D0999	Unspecified diagnostic procedure, by report	Yes	HealthCheck "Other Services." Use this code for up to two additional oral exams per year with a HealthCheck referral. Allowable for members ages 13–20.

¹ Retain records in member files regarding nature of emergency.
² Six-month limitation may be exceeded in an emergency.
³ The same DOS limitation may not be exceeded in an emergency.

D1000–D1999 Preventive

Covered preventive services are identified by the allowable CDT procedure codes listed in the following table. Reimbursement is allowable only for services that meet all program requirements. This includes documenting the medical necessity of services in the member's medical record.

Code	Description of Service	Prior Authorization?	Limitations and Requirements
Dental Prophylaxis
D1110	Prophylaxis — adult	No	One per 12-month period, per member, per provider, for ages 21 and older. One per six-month period, per member, per provider, for ages 13–20. Allowable for members ages 13 or older. Not payable with periodontal scaling and root planing or periodontal maintenance procedure. Special Circumstances: Up to four per 12-month period, per member, per provider, for permanently disabled member. Retain documentation of disability that impairs ability to maintain oral hygiene. Allowable for Medicaid-enrolled dental hygienists.
D1120	Prophylaxis — child	No	One per six-month period, per member, per provider. Allowable for members up to age 12. Special Circumstances: Up to four per 12-month period, per member, per provider, for permanently disabled members. Retain documentation of disability that impairs ability to maintain oral hygiene. Allowable for Medicaid-enrolled dental hygienists.
Topical Fluoride Treatment (Office Procedure)
D1206	Topical application of fluoride varnish	No	Up to two times per 12-month period for members between 0–20 years of age. Once per 12-month period for members 21 years of age and older. Up to four times per 12-month period for a member who has an oral hygiene-impairing disability. Retain documentation of disability that impairs ability to maintain oral hygiene. Up to four times per 12-month period for a member with a high caries risk. Retain documentation of member's high caries risk. Per CDT, not used for desensitization. Not payable with periodontal scaling and root planing. Allowable for Medicaid-enrolled dental hygienists.
D1208	Topical application of fluoride — excluding varnish	No	Up to two times per 12-month period for members between 0–20 years of age. Once per 12-month period for members 21 years of age and older. Up to four times per 12-month period for a member who has an oral hygiene-impairing disability. Retain documentation of disability that impairs ability to maintain oral hygiene. Up to four times per 12-month period for a member with a high caries risk. Retain documentation of member's high caries risk. Not payable with periodontal scaling and root planing. Allowable for Medicaid-enrolled dental hygienists.
Other Preventive Services
D1351	Sealant — per tooth (20 years of age or younger)	No	Sealants are covered for tooth numbers/letters 2, 3, 4, 5, 12, 13, 14, 15, 18, 19, 20, 21, 28, 29, 30, 31, A, B, I, J, K, L, S, and T. Covered once every 3 years per tooth, per member, per provider. Refer to the Sealants Online Handbook topic for limitations and requirements.
D1351	Sealant — per tooth (21 years of age and older)	Yes	Sealants are covered for tooth numbers: 2, 3, 14, 15, 18, 19, 30, and 31. Covered once every 3 years per tooth, per member, per provider. Refer to the Sealants Online Handbook topic for limitations and requirements.
D1354	Application of caries arresting medicament application — per tooth	No	Allowable for treatment of asymptomatic and active dental caries only. Allowable once per tooth, per six-month period for a maximum of five teeth per DOS. Allowable a maximum of four applications per tooth, per lifetime, per member. Allowable for all ages. Not allowable on the same DOS as the restoration of that tooth. Reimbursable when rendered by dentists, dental hygienists, and HealthCheck providers only. Frequency limitation may be exceeded for up to four times per tooth per 12-month period for members with high caries risk. Providers are required to retain documentation demonstrating medical necessity. Additional coverage information is available.
Space Maintenance (Passive Appliances)
D1510	space maintainer — fixed, unilateral — per quadrant	No	First and second primary molar only (tooth letters A, B, I, J, K, L, S, and T only). Limited to four per DOS; once per year, per tooth. Narrative required to exceed frequency limitation. Allowable for members up to age 20. Requires the appropriate area of the oral cavity code for each requested quadrant. Each quadrant must be indicated on a separate detail.
D1516	Space Maintainer — fixed — bilateral, maxillary	No	Once per year. Narrative required to exceed frequency limitation. Allowable for members up to age 20.
D1517	Space Maintainer — fixed — bilateral, mandibular	No	Once per year. Narrative required to exceed frequency limitation. Allowable for members up to age 20.
D1551	re-cement or re-bond bilateral space maintainer — maxillary	No	Allowable for members up to age 20.
D1552	re-cement or re-bond bilateral space maintainer — mandibular	No	Allowable for members up to age 20.
D1553	re-cement or re-bond unilateral space maintainer — per quadrant	No	Allowable for members up to age 20. Requires the appropriate area of the oral cavity code for each requested quadrant. Each quadrant must be indicated on a separate detail.
D1556	removal of fixed unilateral space maintainer — per quadrant	No	Requires the appropriate area of the oral cavity code for each requested quadrant. Each quadrant must be indicated on a separate detail.
D1557	removal of fixed bilateral space maintainer — maxillary	No
D1558	removal of fixed bilateral space maintainer — mandibular	No
D1575	distal shoe space maintainer — fixed, unilateral — per quadrant	No	Second primary molar only (tooth letters A, J, K, and T only). Limited to four per DOS; once per year, per tooth. Narrative required to exceed frequency limitation. Allowable for members up to age 20. Requires the appropriate area of the oral cavity code for each requested quadrant. Each quadrant must be indicated on a separate detail.

D2000–D2999 Restorative

Covered restorative services are identified by the allowable CDT procedure codes listed in the following table. Reimbursement is allowable only for services that meet all program requirements. This includes documenting the medical necessity of services in the member's medical record.

Code	Description of Service	Prior Authorization?	Limitations and Requirements
Amalgam Restorations (Including Polishing)
D2140	Amalgam — one surface, primary or permanent	No	Primary teeth: Once per tooth, per year, per member, per provider¹ (tooth letters A–T and AS–TS only). Permanent teeth: Once per tooth, per three years, per provider¹ (tooth numbers 1–32 and 51–82 only).
D2150	Amalgam — two surfaces, primary or permanent	No	Primary teeth: Once per tooth, per year, per member, per provider¹ (tooth letters A–T and AS–TS only). Permanent teeth: Once per tooth, per three years, per member, per provider¹ (tooth numbers 1–32 and 51–82 only).
D2160	Amalgam — three surfaces, primary or permanent	No	Primary teeth: Once per tooth, per year, per provider¹ (tooth letters A–T and AS–TS only). Permanent teeth: Once per tooth, per three years, per member, per provider¹ (tooth numbers 1–32 and 51–82 only).
D2161	Amalgam — four or more surfaces, primary or permanent	No	Primary teeth: Once per tooth, per year, per member, per provider¹ (tooth letters A–T and AS–TS only). Permanent teeth: Once per tooth, per three years, per member, per provider¹ (tooth numbers 1–32 and 51–82 only).
Resin-Based Composite Restorations — Direct
D2330	Resin-based composite — one surface, anterior	No	Primary teeth: Once per tooth, per year, per member, per provider.¹ Permanent teeth: Once per tooth, per three years, per member, per provider.¹ Allowed for Class I and Class V only (tooth numbers 6–11, 22–27, C–H, M–R, 56–61, 72–77, CS–HS, and MS–RS only).
D2331	Resin-based composite — two surfaces, anterior	No	Primary teeth: Once per tooth, per year, per member, per provider.¹ Permanent teeth: Once per tooth, per three years, per member, per provider.¹ Allowed for Class III only (tooth numbers 6–11, 22–27, C–H, M–R, 56–61, 72–77, CS–HS, and MS–RS only).
D2332	Resin-based composite — three surfaces, anterior	No	Primary teeth: Once per tooth, per year, per member, per provider.¹ Permanent teeth: Once per tooth, per three years, per member, per provider.¹ Allowed for Class III and Class IV only (tooth numbers 6–11, 22–27, C–H, M–R, 56–61, 72–77, CS–HS, and MS–RS only).
D2335	Resin-based composite — four or more surfaces or involving incisal angle (anterior)	No	Primary teeth: Once per tooth, per year, per member, per provider.¹ Permanent teeth: Once per tooth, per three years, per member, per provider.¹ Allowed for Class IV only (tooth numbers 6–11, 22–27, C–H, M–R, 56–61, 72–77, CS–HS, and MS–RS only). Must include incisal angle. Four surface resins may be billed under D2332, unless an incisal angle is included.
D2390	Resin-based composite crown, anterior	No	Primary teeth: Once per year, per tooth (tooth letters D–G, DS–GS only). Permanent teeth: Once per five years, per tooth (tooth numbers 6–11, 22–27, 56–61, 72–77 only.) Limitation can be exceeded with narrative for children,¹ and with PA for adults greater than age 20.²
D2391	Resin-based composite — one surface, posterior	No	Primary teeth: Once per year, per member, per provider, per tooth¹ (tooth letters A, B, I, J, K, L, S, T, AS, BS, IS, JS, KS, LS, SS, and TS only). Permanent teeth: Once per three years, per member, per provider, per tooth¹ (tooth numbers 1–5, 12–21, 28–32, 51–55, 62–71, and 78–82 only).
D2392	Resin-based composite — two surfaces, posterior	No	Primary teeth: Once per year, per member, per provider, per tooth¹ (tooth letters A, B, I, J, K, L, S, T, AS, BS, IS, JS, KS, LS, SS, and TS only). Permanent teeth: Once per three years, per member, per provider, per tooth¹ (tooth numbers 1–5, 12–21, 28–32, 51–55, 62–71, and 78–82 only).
D2393	Resin-based composite — three surfaces, posterior	No	Primary teeth: Once per year, per member, per provider, per tooth¹ (tooth letters A, B, I, J, K, L, S, T, AS, BS, IS, JS, KS, LS, SS, and TS only). Permanent teeth: Once per three years, per member, per provider, per tooth¹ (tooth numbers 1–5, 12–21, 28–32, 51–55, 62–71, and 78–82 only).
D2394	Resin-based composite — four or more surfaces, posterior	No	Primary teeth: Once per year, per member, per provider, per tooth¹ (tooth letters A, B, I, J, K, L, S, T, AS, BS, IS, JS, KS, LS, SS, and TS only). Permanent teeth: Once per three years, per member, per provider, per tooth¹ (tooth numbers 1–5, 12–21, 28–32, 51–55, 62–71, and 78–82 only).
Crowns — Single Restorations Only
D2791	Crown — full cast predominantly base metal	No	Once per year, per primary tooth; once per five years, per permanent tooth² (tooth numbers 1–32, A–T, 51–82, and AS–TS.) Reimbursement is limited to the rate of code D2933. Upgraded crown. No dentist is obligated to complete this type of crown.
Other Restorative Services
D2910	Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration	No	Tooth numbers 1–32, 51–82 only.
D2915	Re-cement or re-bond indirectly fabricated or prefabricated post and core	No	Tooth numbers 1–32, A–T, 51–82, AS–TS.
D2920	Re-cement or re-bond crown	No	Tooth numbers 1–32, A–T, 51–82, AS–TS.
D2928	Prefabricated porcelain/ceramic crown — permanent tooth	No	Once per five years, per tooth (tooth numbers 1–32 and 51–82 only).
D2929	Prefabricated porcelain/ceramic crown — primary tooth	No	Once per year, per tooth (tooth letters A–T and AS–TS only).²
D2930	Prefabricated stainless steel crown — primary tooth	No	Once per year, per tooth (tooth letters A–T and AS–TS only).²
D2931	Prefabricated stainless steel crown — permanent tooth	No	Once per five years, per tooth (tooth numbers 1–32 and 51–82 only).
D2932	Prefabricated resin crown	No	Primary teeth: Once per year, per tooth (tooth letters D–G and DS–GS only). Permanent teeth: Once per five years, per tooth (tooth numbers 6–11, 22–27, 56–61, and 72–77 only.) Limitation can be exceeded with narrative for children,¹ and with PA for adults older than age 20.²
D2933	Prefabricated stainless steel crown with resin window	No	Primary teeth: Once per year, per tooth (tooth letters D–G, DS–GS only). Permanent teeth: Once per five years, per tooth (tooth numbers 6–11 and 56–61 only.) Limitation can be exceeded with narrative for children,¹ and with PA for adults older than age 20.²
D2934	Prefabricated esthetic coated stainless steel crown — primary tooth	No	Once per year, per tooth. Allowable for members up to age 20. Tooth letters D–G and DS–GS only.
D2940	Protective restoration	No	Not allowed with pulpotomies, permanent restorations, or endodontic procedures (tooth numbers 1–32, A–T, 51–82, and AS–TS).
D2951	Pin retention — per tooth, in addition to restoration	No	Once per three years, per tooth (tooth numbers 1–32 and 51–82 only).¹
D2952	Post and core in addition to crown, indirectly fabricated	No	Once per tooth, per lifetime, per member, per provider. Tooth numbers 2–15, 18–31, 52–65, and 68–81 only. Cannot be billed with D2954.
D2954	Prefabricated post and core in addition to crown	No	Once per tooth, per lifetime, per member, per provider. Tooth numbers 2–15, 18–31, 52–65, and 68–81 only. Cannot be billed with D2952.
D2971	Additional procedures to customize a crown to fit under an existing partial denture framework	No	Tooth numbers 2–15 and 18–31 only.
D2999	Unspecified restorative procedure, by report	Yes	HealthCheck "Other Services." Use this code for single-unit crown. Allowable for members up to age 20.

¹ Limitation may be exceeded if narrative on claim demonstrates medical necessity for replacing a properly completed filling, crown, or adding a restoration on any tooth surface. Limitation may be exceeded for non-prior authorized crowns by indicating medical necessity.
² Frequency limitation may be exceeded only with PA.

D3000–D3999 Endodontics

Covered endodontic services are identified by the allowable CDT procedure codes listed in the following table. Reimbursement is allowable only for services that meet all program requirements. This includes documenting the medical necessity of services in the member's medical record.

Code	Description of Service	Prior Authorization?	Limitations and Requirements
Pulpotomy
D3220	Therapeutic pulpotomy (excluding final restoration) — removal of pulp coronal to the dentinocemental junction and application of medicament	No	Once per tooth, per lifetime. Primary teeth only (tooth letters A–T and AS–TS only).
D3221	Pulpal debridement, primary and permanent teeth	No	Allowable for tooth numbers 2–15, 18–31, 52–65, and 68–81 only. For primary teeth, use D3220. Not to be used by provider completing endodontic treatment.
D3222	Partial pulpotomy for apexogenesis — permanent tooth with incomplete root development	No	Allowable for members through age 12.
Endodontic Therapy (Including Treatment Plan, Clinical Procedures and Follow-Up Care)
D3310	Endodontic therapy, anterior tooth (excluding final restoration)	No (see limitations)	Normally for permanent anterior teeth. May be used to bill a single canal on a bicuspid or molar (tooth numbers 2–15, 18–31, 52–65, and 68–81 only, once per tooth, per lifetime). Not allowed with sedative filling. Root canal therapy for all ages on four or more teeth requires a PA.
D3320	Endodontic therapy, premolar tooth (excluding final restoration)	No (see limitations)	Normally for permanent premolar teeth. May be used to bill two canals on a premolar or molar (tooth numbers 2–5, 12–15, 18–21, 28–31, 52–55, 62–65, 68–71, and 78–81 only, once per tooth, per lifetime). Not allowed with sedative filling. Root canal therapy for all ages on four or more teeth requires a PA.
D3330	Endodontic therapy, molar tooth (excluding final restoration)	Yes, if age >20	Not covered for third molars. Permanent teeth only (tooth numbers 2, 3, 14, 15, 18, 19, 30, 31, 53, 53, 64, 65, 68, 69, 80, and 81 only, once per tooth, per lifetime). Not allowed with sedative filling. Root canal therapy for all ages on four or more teeth requires a PA.
Apexification/Recalcification
D3351	Apexification/recalcification — initial visit (apical closure/calcific repair of perforations, root resorption, etc.)	No	Permanent teeth only (tooth numbers 2–15, 18–31 only). Not allowable with root canal therapy. Allowable for members up to age 20.¹
D3352	Apexification/recalcification — interim medication replacement (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.)	No	Limited to one unit per day with a two-unit maximum per lifetime, per tooth. Permanent teeth only (tooth numbers 2–15, 18–31 only). Not allowable with root canal therapy. Allowable for members up to age 20.¹
D3353	Apexification/recalcification — final visit (includes completed root canal therapy — apical closure/calcific repair of perforations, root resorption, etc.)	No	Limited to one unit per day with a one-unit maximum per lifetime, per tooth. Permanent teeth only (tooth numbers 2–15, 18–31 only). Not allowable with root canal therapy. Allowable for members up to age 20.¹
Apicoectomy/Periradicular Services
D3410	Apicoectomy — anterior	No	Permanent anterior teeth only (tooth numbers 6–11, 22–27, 56–61, and 72–77 only). Not payable with root canal therapy on the same DOS. Code does not include retrograde filling (D3430), which may be billed separately.
D3430	Retrograde filling — per root	No	Permanent anterior teeth only (tooth numbers 6–11, 22–27, 56–61, and 72–77 only). Not payable with root canal therapy on the same DOS.

¹ Following reimbursement of an apexification procedure (initial visit, interim visit, or final visit), ForwardHealth will not reimburse any of the following procedures for a lifetime on the same tooth: pulpal debridement of permanent tooth, partial pulpotomy for apexogenesis, or endodontic therapy of an anterior, premolar, or molar tooth.

D4000-D4999 Periodontics

Covered periodontal services are identified by the allowable CDT procedure codes listed in the following table. Reimbursement is allowable only for services that meet all program requirements. This includes documenting the medical necessity of services in the member's medical record.

Code	Description of Service	Prior Authorization?	Limitations and Requirements
Surgical Services (Including Usual Postoperative Care)
D4210	Gingivectomy or gingivoplasty — four or more contiguous teeth or tooth bounded spaces per quadrant	Yes	Allowable area of oral cavity codes: 10 (upper right), 20 (upper left), 30 (lower left), and 40 (lower right).
D4211	Gingivectomy or gingivoplasty — one to three contiguous teeth or tooth bounded spaces per quadrant	Yes	Allowable area of oral cavity codes: 10 (upper right), 20 (upper left), 30 (lower left), and 40 (lower right).
Non-Surgical Periodontal Service
D4341	Periodontal scaling and root planing — four or more teeth per quadrant	Yes	Allowable area of oral cavity codes: 10 (upper right), 20 (upper left), 30 (lower left), and 40 (lower right). Allowable for members ages 13 and older. Limited in most circumstances to once per three years per quadrant. Up to four quadrants per DOS are allowed when provided in hospital or ASC POS. Limited to two quadrants per DOS when provided in an office, home, ECF, or other POS, unless the PA request provides sound medical or other logical reasons, including long distance travel to the dentist or disability that makes travel to the dentist difficult, for up to four quadrants per DOS. Not payable with prophylaxis or a fluoride treatment.
D4342	Periodontal scaling and root planing — one to three teeth per quadrant	Yes	Allowable area of oral cavity codes: 10 (upper right), 20 (upper left), 30 (lower left), and 40 (lower right). Allowable for members ages 13 and older. Limited in most circumstances to once per three years per quadrant. Up to four quadrants per DOS are allowed when provided in a hospital or ASC POS. Limited to two quadrants per DOS when provided in an office, home, ECF, or other POS, unless the PA request provides sound medical or other logical reasons, including long distance travel to the dentist or disability that makes travel to the dentist difficult, for up to four quadrants per DOS. Not payable with prophylaxis or a fluoride treatment.
D4346	Scaling in presence of generalized moderate or severe gingival inflammation — full mouth, after oral evaluation	No	Full mouth code. Moderate to severe gingival inflammation must be present and documented in the medical or dental record. No other periodontal treatment (D4341, D4342, or D4910) can be authorized immediately after this procedure. D4346 and D4355 cannot be reported on same day. Not payable with prophylaxis. Allowable for all members.
D4355	Full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit	No (see limitations)	Full mouth code. Excess calculus must be evident on an X-ray. One per three years, per member, per provider. Billed on completion date only. May be completed in one long appointment. No other periodontal treatment (D4341, D4342, or D4910) can be authorized immediately after this procedure. Includes tooth polishing. Not payable with prophylaxis. Allowable for members ages 13 and older. Allowable with PA for members ages 0-12. D4355 and D4346 cannot be reported on same day.
Other Periodontal Services
D4910	Periodontal maintenance	Yes	PA may be granted up to three years. Not payable with prophylaxis. Once per year in most cases. Allowable for members ages 13 and older.
D4999	Unspecified periodontal procedure, by report	Yes	HealthCheck "Other Services." Use this code for unspecified surgical procedure with a HealthCheck referral. Allowable for members up to age 20.

D9000–D9999 Adjunctive General Services

Covered adjunctive general services are identified by the allowable CDT procedure codes listed in the following table. Reimbursement is allowable only for services that meet all program requirements. This includes documenting the medical necessity of services in the member's medical record.

Code	Description of Service	Prior Authorization?	Limitations and Requirements
Unclassified Treatment
D9110	Palliative (emergency) treatment of dental pain — minor procedure	No	Not payable immediately before or after surgery. Emergency only. Limit of $62.50 reimbursement per DOS for all emergency procedures done on a single DOS. Narrative required to override limitations.
Anesthesia
D9222	Deep sedation/general anesthesia — first 15 minutes	Yes (see limitations)	PA not required in the following circumstances: For hospital or ASC POS. In an emergency.¹ For children (ages 0–20), when performed by an oral surgeon or pediatric dentist. Reimbursement maximum is 15 minutes. Not billable to the member. Bill only D9222 and D9223 for general anesthesia. Not payable with D9230, D9243, or D9248.
D9223	Deep sedation/general anesthesia — each subsequent 15 minute increment	Yes (see limitations)	PA not required in the following circumstances: For hospital or ASC POS. In an emergency.¹ For children (ages 0–20), when performed by an oral surgeon or pediatric dentist. Reimbursement maximum is 30 minutes (two 15-minute unit increments). Not billable to the member. Bill only D9222 and D9223 for general anesthesia. Not payable with D9230, D9243, or D9248.
D9230	Inhalation of nitrous oxide/analgesia, anxiolysis (20 years of age or younger)	Yes (Except pediatric dentists and oral surgeons)	Allowable for children (ages 0–20) without PA, when performed by an oral surgeon or pediatric dentist. All other providers require PA. Not payable with D9223, D9243, or D9248. Billable as one unit per DOS. Refer to the Inhalation of Nitrous Oxide Online Handbook topic for limitations and requirements.
D9230	Inhalation of nitrous oxide/analgesia, anxiolysis (21 years of age and older)	Yes	Allowable for members 21 and older with PA when an emergency extraction is needed or the member has been diagnosed with a permanent physical, developmental, or intellectual disability, or has a documented medical condition that impairs their ability to maintain oral hygiene or anxiety disorder. Not payable with D9223, D9243, or D9248. Billable as one unit per DOS. Refer to the Inhalation of Nitrous Oxide Online Handbook topic for limitations and requirements.
D9239	Intravenous moderate (conscious) sedation/analgesia — first 15 minutes	Yes (see limitations)	PA not required in the following circumstances: For hospital or ASC POS. In an emergency.¹ For children (ages 0–20), when performed by an oral surgeon or pediatric dentist. Reimbursement maximum is 15 minutes. Not billable to the member. Bill only D9239 and D9243 for intravenous sedation. Not payable with D9223, D9230, or D9248.
D9243	Intravenous moderate (conscious) sedation/analgesia — each subsequent 15 minute increment	Yes (see limitations)	PA not required in the following circumstances: For hospital or ASC POS. In an emergency.¹ For children (ages 0–20), when performed by an oral surgeon or pediatric dentist. Reimbursement maximum is 30 minutes (two 15-minute unit increments). Not billable to the member. Bill only D9239 and D9243 for intravenous sedation. Not payable with D9223, D9230, or D9248.
D9248	Non-intravenous conscious sedation	Yes (see limitations)	PA not required for children (ages 0–20), when performed by an oral surgeon or pediatric dentist. Not analgesia. Not payable with D9223, D9230, or D9243. Not inhalation of nitrous oxide.
Professional Visits
D9410	House/extended care facility call	No	Reimbursed for professional visits to nursing homes and skilled nursing facilities. Only reimbursed for claims that indicate POS code 31 (skilled nursing facility) or 32 (nursing home). Service is limited to once every 333 days per member, per provider. Service must be performed by a Medicaid-enrolled dentist.
D9420	Hospital or ambulatory surgical center call	No	Up to two visits per stay. Only allowable in hospital and ASC POS.
Drugs
D9610	Therapeutic parenteral drug, single administration	No
D9612	Therapeutic parenteral drugs, two or more administrations, different medications	No
D9613	Infiltration of sustained release therapeutic drug — per quadrant	No
Miscellaneous Services
D9910	Application of desensitizing medicament	No	Tooth numbers 1–32, A–T, 51–82, and AS–TS. Limit of $62.50 reimbursement per DOS for all emergency procedures done on a single DOS. Narrative required to override limitations. Not payable immediately before or after surgery, or periodontal procedures (D4210, D4211, D4341, D4342, D4355, D4910). Cannot be billed for routine fluoride treatment. Emergency only.
D9944	Occlusal guard — hard appliance, full arch (20 years of age or younger)	Yes	Allowable with PA for members 20 years of age and younger. Coverage is limited to one occlusal guard type per year. Refer to the Occlusal Guards Online Handbook topic for limitations and requirements.
D9944	Occlusal guard — hard appliance, full arch (21 years of age and older)	Yes	Allowable with PA for members 21 years of age and older who have been medically diagnosed with a permanent physical, developmental, or intellectual disability, or have a documented medical condition that impairs their ability to maintain oral hygiene. Coverage is limited to one occlusal guard type per year. Refer to the Occlusal Guards Online Handbook topic for limitations and requirements.
D9945	Occlusal guard — soft appliance, full arch (20 years of age or younger)	Yes	Allowable with PA for members 20 years of age or younger. Coverage is limited to one occlusal guard type per year. Refer to the Occlusal Guards Online Handbook topic for limitations and requirements.
D9945	Occlusal guard — soft appliance, full arch (21 years of age and older)	Yes	Allowable with PA for members 21 years of age and older who have been medically diagnosed with a permanent physical, developmental, or intellectual disability, or have a documented medical condition that impairs their ability to maintain oral hygiene. Coverage is limited to one occlusal guard type per year. Refer to the Occlusal Guards Online Handbook topic for limitations and requirements.
D9946	Occlusal guard — hard appliance, partial arch (20 years of age or younger)	Yes	Allowable with PA for members 20 years of age or younger. Coverage is limited to one occlusal guard type per year. Refer to the Occlusal Guards Online Handbook topic for limitations and requirements.
D9946	Occlusal guard — hard appliance, partial arch (21 years of age and older)	Yes	Allowable with PA for members 21 years of age and older who have been medically diagnosed with a permanent physical, developmental, or intellectual disability, or have a documented medical condition that impairs their ability to maintain oral hygiene. Coverage is limited to one occlusal guard type per year. Refer to the Occlusal Guards Online Handbook topic for limitations and requirements.
D9995	Teledentistry synchronous; real-time encounter	No	Refer to the Teledentistry Policy topic for limitations and requirement.
D9999	Unspecified adjunctive procedure, by report	Yes	HealthCheck "Other Services." Use this code for unspecified non-surgical procedures with a HealthCheck referral.
E0486 — EP	Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment	Yes	Allowable with PA for members 20 years of age or younger when criteria are met. Coverage limited to one oral device/appliance per year. HealthCheck screening within the last 365 days is required. Refer to the Oral Devices/Appliances Online Handbook topic for limitations and requirements.

¹Retain records in member files regarding nature of emergency.

Topic #2818

Information is available for DOS before January 1, 2024.

BadgerCare Plus/Medicaid Prosthodontics, Maxillofacial Prosthetics, Maxillofacial Surgery, and Orthodontics

The following procedure codes are covered under BadgerCare Plus and Medicaid.

D5000–D5899 Prosthodontics, Removable

Covered removable prosthodontic services are identified by the allowable CDT procedure codes listed in the following table. Medicaid reimbursement is allowable only for services that meet all program requirements. This includes documenting the medical necessity of services in the member's medical record.

Code	Description of Service	Prior Authorization?	Limitations and Requirements
Complete Dentures (Including Routine Post-Delivery Care)
D5110	Complete denture—maxillary	Yes	Allowed once per five years.^{1, 2}
D5120	Complete denture—mandibular	Yes	Allowed once per five years.^{1, 2}
Partial Dentures (Including Routine Post-Delivery Care)
D5211	Maxillary (upper) partial denture; resin base (including any conventional clasps, rests and teeth)	Yes	Allowed once per five years.^{1, 2}
D5212	Mandibular (lower) partial denture; resin base (including any conventional clasps, rests and teeth)	Yes	Allowed once per five years.^{1, 2}
D5213	Maxillary partial denture; cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)	Yes	Allowed once per five years.^{1, 2} Reimbursement is limited to reimbursement for D5211. Upgraded partial denture. No dentist is obligated to complete this type of partial.
D5214	Mandibular partial denture; cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)	Yes	Allowed once per five years.^{1, 2} Reimbursement is limited to reimbursement for D5212. Upgraded partial denture. No dentist is obligated to complete this type of partial.
D5225	Maxillary partial denture—flexible base (including any clasps, rests and teeth)	Yes	Allowed once per five years.^{1, 2}
D5226	Mandibular partial denture—flexible base (including any clasps, rests and teeth)	Yes	Allowed once per five years.^{1, 2}
Repairs to Complete Dentures
D5511	Repair broken complete denture base, mandibular	No	Combined maximum reimbursement limit per six months for repairs.
D5512	Repair broken complete denture base, maxillary	No	Combined maximum reimbursement limit per six months for repairs.
D5520	Replace missing or broken teeth—complete denture (each tooth)	No	Combined maximum reimbursement limit per six months for repairs.
Repairs to Partial Dentures
D5611	Repair resin partial denture base, mandibular	No	Combined maximum reimbursement limit per six months for repairs.
D5612	Repair resin partial denture base, maxillary	No	Combined maximum reimbursement limit per six months for repairs.
D5621	Repair cast partial framework, mandibular	No	Combined maximum reimbursement limit per six months for repairs.
D5622	Repair cast partial framework, maxillary	No	Combined maximum reimbursement limit per six months for repairs.
D5630	Repair or replace broken clasp—per tooth	No	Combined maximum reimbursement limit per six months for repairs. Requires an area of oral cavity code (01=Maxillary or 02=Mandibular) in the appropriate element of the claim form. Requires tooth numbers on claim submission.
D5640	Replace broken teeth—per tooth	No	Combined maximum reimbursement limit per six months for repairs. Requires an area of oral cavity code (01=Maxillary or 02=Mandibular) in the appropriate element of the claim form.
D5650	Add tooth to existing partial denture	No	Combined maximum reimbursement limit per six months for repairs. Requires an area of oral cavity code (01=Maxillary or 02=Mandibular) in the appropriate element of the claim form.
D5660	Add clasp to existing partial denture—per tooth	No	Combined maximum reimbursement limit per six months for repairs. Requires an area of oral cavity code (01=Maxillary or 02=Mandibular) in the appropriate element of the claim form. Requires tooth numbers on claim submission.
D5670	Replace all teeth and acrylic on cast metal framework (maxillary)	Yes	Combined maximum reimbursement limit per six months for repairs. Requires area of oral cavity code 01=Maxillary in the appropriate element of the claim form.
D5671	Replace all teeth and acrylic on cast metal framework (mandibular)	Yes	Combined maximum reimbursement limit per six months for repairs. Requires area of oral cavity code 02=Mandibular in the appropriate element of the claim form.
Denture Reline Procedures
D5750	Reline complete maxillary denture (laboratory)	No	Allowed once per three years.¹ Retain documentation of medical necessity.
D5751	Reline complete mandibular denture (laboratory)	No	Allowed once per three years.¹ Retain documentation of medical necessity.
D5760	Reline maxillary partial denture (laboratory)	No	Allowed once per three years.¹ Retain documentation of medical necessity.
D5761	Reline mandibular partial denture (laboratory)	No	Allowed once per three years.¹ Retain documentation of medical necessity.

¹ Frequency limitation may be exceeded in exceptional circumstances with written justification on PA request.
² Healing period of six weeks required after last extraction prior to taking impressions for dentures, unless shorter period approved in PA.

21076–21089, D5900–D5999 Maxillofacial Prosthetics

Covered maxillofacial prosthetics are identified by the allowable procedure codes listed in the following table. Medicaid reimbursement is allowable only for services that meet all program requirements. This includes documenting the medical necessity of services in the member's medical record.

Code	Description of Service	Prior Authorization?	Limitations and Requirements
21076	Impression and custom preparation; surgical obturator prosthesis	Yes	Allowed once per six months. Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.
21077	Impression and custom preparation; orbital prosthesis	Yes	Allowed once per six months. Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.
21079	Impression and custom preparation; interim obturator prosthesis	Yes	Allowed once per six months. Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.
21080	Impression and custom preparation; definitive obturator prosthesis	Yes	Allowed once per six months. Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.
21081	Impression and custom preparation; mandibular resection prosthesis	Yes	Allowed once per six months. Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.
21082	Impression and custom preparation; palatal augmentation prosthesis	Yes	Allowed once per six months. Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.
21083	Impression and custom preparation; palatal lift prosthesis	Yes	Allowed once per six months. Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.
21084	Impression and custom preparation; speech aid prosthesis	Yes	Allowed once per six months. Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.
21085	Impression and custom preparation; oral surgical splint	Yes	Allowed once per six months. Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.
21086	Impression and custom preparation; auricular prosthesis	Yes	Allowed once per six months. Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.
21087	Impression and custom preparation; nasal prosthesis	Yes	Allowed once per six months. Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.
21088	Impression and custom preparation; facial prosthesis	Yes	Allowed once per six months. Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.
21089	Unlisted maxillofacial prosthetic procedure	Yes	Allowed once per six months. Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.
D5932	Obturator prosthesis, definitive	No	Allowed once per six months.¹ Retain documentation of medical necessity.
D5955	Palatal lift prosthesis, definitive	No	Allowed once per six months.¹ Retain documentation of medical necessity.
D5991	Topical medicament carrier	No
D5999	Unspecified maxillofacial prosthesis, by report	Yes	For medically necessary removable prosthodontic procedures. Use this code only if a service is provided that is not accurately described by other HCPCS or CPT procedure codes.

¹ Frequency limitation may be exceeded in exceptional circumstances with written justification on PA request.

D6200–D6999 Prosthodontics, Fixed

Covered fixed prosthodontic services are identified by the allowable CDT procedure codes listed in the following table. Medicaid reimbursement is allowable only for services that meet all program requirements. This includes documenting the medical necessity of services in the member's medical record.

Code	Description of Service	Prior Authorization?	Limitations and Requirements
Fixed Partial Denture Pontics
D6211	Pontic—cast predominantly base metal	Yes	Permanent teeth only (tooth numbers 1–32 and 51–82 only).
D6241	Pontic—porcelain fused to predominantly base metal	Yes	Permanent teeth only (tooth numbers 1–32 and 51–82 only).
Fixed Partial Denture Retainers—Inlays/Onlays
D6545	Retainer; cast metal for resin bonded fixed prosthesis	Yes	Tooth numbers 1–32, 51–82 only.
Fixed Partial Denture Retainers—Crowns
D6751	Retainer crown—porcelain fused to predominantly base metal	Yes	Permanent teeth only (tooth numbers 1–32 and 51–82 only).
D6791	Retainer crown—full cast predominantly base metal	Yes	Permanent teeth only (tooth numbers 1–32 and 51–82 only).
Other Fixed Partial Denture Services
D6930	Recement fixed partial denture	No
D6940	Stress breaker	Yes	Copy of lab bill required.
D6980	Fixed partial denture repair, by report	Yes	Copy of lab bill required.
D6985	Pediatric partial denture, fixed	No	Allowable up to age 12. Retain documentation of medical necessity.

D7000–D7999 Oral and Maxillofacial Surgery

Covered oral and maxillofacial surgery services are identified by the allowable CDT procedure codes listed in the following table. Medicaid reimbursement is allowable only for services that meet all program requirements. This includes documenting the medical necessity of services in the member's medical record.

Code	Description of Service	Prior Authorization?	Limitations and Requirements
Extractions (Includes local anesthesia, suturing, if needed, and routine postoperative care)
D7111	Extraction, coronal remnants—primary tooth	No	Allowed only once per tooth. Primary teeth only (tooth letters A–T and AS–TS only). Not payable same DOS as D7250 for same tooth letter.
D7140	Extraction, erupted tooth or exposed root (elevation and/or forceps removal)	No	Allowed only once per tooth (tooth numbers 1–32, A–T, 51–82 and AS–TS). Not payable same DOS as D7250 for same tooth number.
Surgical Extractions (Includes local anesthesia, suturing, if needed, and routine postoperative care)
D7210	Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated	No	Allowed only once per tooth. Covered when performing an emergency service or for orthodontia (tooth numbers 1–32, A–T, 51–82 and AS–TS).¹ Not payable same DOS as D7250 for same tooth number.
D7220	Removal of impacted tooth—soft tissue	No	Allowed only once per tooth. Covered when performing an emergency service or for orthodontia (tooth numbers 1–32, A–T, 51–82 and AS–TS).¹ Not payable same DOS as D7250 for the same tooth number.
D7230	Removal of impacted tooth—partially bony	No	Allowed only once per tooth. Covered when performing an emergency service or for orthodontia (tooth numbers 1–32, A–T, 51–82 and AS–TS).¹ Not payable same DOS as D7250 for the same tooth number.
D7240	Removal of impacted tooth—completely bony	No	Allowed only once per tooth. Covered when performing an emergency service or for orthodontia (tooth numbers 1–32, A–T, 51–82 and AS–TS).¹ Not payable same DOS as D7250 for the same tooth number.
D7241	Removal of impacted tooth—completely bony, with unusual surgical complications	No	Allowed only once per tooth. Covered when performing an emergency service or for orthodontia (tooth numbers 1–32, A–T, 51–82 and AS–TS).¹ Not payable same DOS as D7250 for the same tooth number.
D7250	Removal of residual tooth roots (cutting procedure)	No	Emergency only (tooth numbers 1–32, A–T, 51–82 and AS–TS).¹ Allowed only once per tooth. Not allowed on the same DOS as tooth extraction of same tooth number.
Other Surgical Procedures
D7260 or CPT²	Oroantral fistula closure	No	Operative report required on claim submission.
D7261	Primary closure of a sinus perforation	No	Operative report required on claim submission.
D7270	Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth	No	Emergency only (tooth numbers 1–32, C–H, M–R, 51–82, CS–HS, and MS–RS).¹ Operative report required on claim submission.
D7280	Exposure of an unerupted tooth	No	Not allowed for primary or wisdom teeth (tooth numbers 2–15, 18–31, 52–65, and 68–81 only). Allowable for members ages 0–20. Covered for orthodontic reasons. Clinical notes and an operative report must be retained in the member's medical or dental record.
D7282	Mobilization of erupted or malpositioned tooth to aid eruption	No	Not allowed for primary or wisdom teeth (tooth numbers 2–15, 18–31, 52–65, and 68–81 only). Allowable for members ages 0–20. Covered for orthodontic reasons. Clinical notes and an operative report must be retained in the member's medical or dental record.
D7283	Placement of device to facilitate eruption of impacted tooth	No	Not allowed for primary or wisdom teeth (tooth numbers 2–15, 18–31, 52–65, and 68–81 only). Allowable for members ages 0–20. Covered for orthodontic reasons. Clinical notes and an operative report must be retained in the member's medical or dental record.
D7284	Excisional biopsy of minor salivary glands	No	Once per DOS.³
D7285 or CPT²	Incisional biopsy of oral tissue—hard (bone, tooth)	No	Once per DOS.³ Operative report required on claim submission.
D7286 or CPT²	Incisional biopsy of oral tissue—soft	No	Once per DOS.³ Operative report required on claim submission.
D7287 or CPT²	Exfoliative cytological sample collection	No	Once per DOS.³ Operative report required on claim submission.
D7288	Brush biopsy—transepithelial sample collection	No	Once per DOS.³ Operative report required on claim submission.
Alveoloplasty—Surgical Preparation of Ridge for Dentures
D7310	Alveoloplasty in conjuction with extractions—per quadrant	No	Allowable area of oral cavity codes: 10 (upper right), 20 (upper left), 30 (lower left), 40 (lower right). X-ray, treatment notes and treatment plan required.
D7311	Alveoloplasty in conjuction with extractions—one to three teeth or tooth spaces, per quadrant	No	Allowable area of oral cavity codes: 10 (upper right), 20 (upper left), 30 (lower left), 40 (lower right). X-ray, treatment notes and treatment plan required.
D7320	Alveoloplasty not in conjuction with extractions—per quadrant	No	Allowable area of oral cavity codes: 10 (upper right), 20 (upper left), 30 (lower left), 40 (lower right). X-ray, treatment notes and treatment plan required.
D7321	Alveoloplasty not in conjuction with extractions—one to three teeth or tooth spaces, per quadrant	No	Allowable area of oral cavity codes: 10 (upper right), 20 (upper left), 30 (lower left), 40 (lower right). X-ray, treatment notes and treatment plan required.
Surgical Excision of Soft Tissue Lesions
D7410 or CPT²	Excision of benign lesion up to 1.25 cm	No	Once per DOS.³ Pathology report required.
D7411 or CPT²	Excision of benign lesion greater than 1.25 cm	No	Once per DOS.³ Pathology report required.
D7412 or CPT²	Excision of benign lesion, complicated	No	Once per DOS.³ Pathology report required.
D7413 or CPT²	Excision of malignant lesion up to 1.25 cm	No	Once per DOS.³ Pathology report required.
D7414 or CPT²	Excision of malignant lesion greater than 1.25 cm	No	Once per DOS.³ Pathology report required.
D7415 or CPT²	Excision of malignant lesion, complicated	No	Once per DOS.³ Pathology report required.
Surgical Excision of Intra-Osseous Lesions
D7440 or CPT²	Excision of malignant tumor—lesion diameter up to 1.25 cm	No	Once per DOS.³ Pathology report required.
D7441 or CPT²	Excision of malignant tumor—lesion diameter greater than 1.25 cm	No	Once per DOS.³ Pathology report required.
D7450 or CPT²	Removal of benign odontogenic cyst or tumor—lesion diameter up to 1.25 cm	No	Once per DOS.³ Pathology report required.
D7451 or CPT²	Removal of benign odontogenic cyst or tumor—lesion diameter greater than 1.25 cm	No	Once per DOS.³ Pathology report required.
D7460 or CPT²	Removal of benign nonodontogenic cyst or tumor—lesion diameter up to 1.25 cm	No	Once per DOS.³ Pathology report required.
D7461 or CPT²	Removal of benign nonodontogenic cyst or tumor—lesion diameter greater than 1.25 cm	No	Once per DOS.³ Pathology report required.
Excision of Bone Tissue
D7471 or CPT²	Removal of lateral exostosis (maxilla or mandible)	Yes	Oral photographic image or diagnostic cast of arch required for PA.
D7472 or CPT²	Removal of torus palatinus	Yes	Oral photographic image or diagnostic cast of arch required for PA.
D7473 or CPT²	Removal of torus mandibularis	Yes	Oral photographic image or diagnostic cast of arch required for PA.
D7485 or CPT²	Surgical reduction of osseous tuberosity	No	Operative report required on claim submission.
D7490 or CPT²	Radical resection of maxilla or mandible	No	Operative report required on claim submission. Only allowable in hospital or ambulatory surgical center POS.
Surgical Incision
D7509	Marsupialization of odontogenic cyst	No
D7510 or CPT²	Incision and drainage of abscess—intraoral soft tissue	No	Operative report required on claim submission. Not to be used for periodontal abscess—use D9110.
D7511 or CPT²	Incision and drainage of abscess—intraoral soft tissue—complicated (includes drainage of multiple fascial spaces)	No	Operative report required on claim submission. Not to be used for periodontal abscess—use D9110.
D7520 or CPT²	Incision and drainage of abscess—extraoral soft tissue	No	Operative report required on claim submission.
D7521 or CPT²	Incision and drainage of abscess—extraoral soft tissue—complicated (includes drainage of multiple fascial spaces)	No	Operative report required on claim submission.
D7530 or CPT²	Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue	No	Not allowed for removal of root fragments and bone spicules. (Use D7250 instead.) Operative report required on claim submission.
D7540 or CPT²	Removal of reaction producing foreign bodies, musculoskeletal system	No	Not allowed for removal of root fragments and bone spicules. (Use D7250 instead.) Operative report required on claim submission.
D7550 or CPT²	Partial ostectomy/sequestrectomy for removal of non-vital bone	No	Operative report required on claim submission.
D7560 or CPT²	Maxillary sinusotomy for removal of tooth fragment or foreign body	No	Operative report required on claim submission.
Treatment of Fractures—Simple
D7610 or CPT²	Maxilla—open reduction (teeth immobilized, if present)	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission.
D7620 or CPT²	Maxilla—closed reduction (teeth immobilized, if present)	No	Operative report required on claim submission.
D7630 or CPT²	Mandible—open reduction (teeth immobilized, if present)	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission.
D7640 or CPT²	Mandible—closed reduction (teeth immobilized, if present)	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission.
D7650 or CPT²	Malar and/or zygomatic arch—open reduction	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission.
D7660 or CPT²	Malar and/or zygomatic arch—closed reduction	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission.
D7670 or CPT²	Alveolus—closed reduction, may include stabilization of teeth	No	Operative report required on claim submission.
D7671 or CPT²	Alveolus—open reduction, may include stabilization of teeth	No	Operative report required on claim submission.
D7680 or CPT²	Facial bones—complicated reduction with fixation and multiple surgical approaches	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission.
Treatment of Fractures—Compound
D7710 or CPT²	Maxilla—open reduction	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission.
D7720 or CPT²	Maxilla—closed reduction	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission.
D7730 or CPT²	Mandible—open reduction	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission.
D7740 or CPT²	Mandible—closed reduction	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission.
D7750 or CPT²	Malar and/or zygomatic arch—open reduction	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission.
D7760 or CPT²	Malar and/or zygomatic arch—closed reduction	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission.
D7770 or CPT²	Alveolus—open reduction stabilization of teeth	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission.
D7771 or CPT²	Alveolus—closed reduction stabilization of teeth	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission.
D7780 or CPT²	Facial bones—complicated reduction with fixation and multiple approaches	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission.
Reduction of Dislocation and Management of Other Temporomandibular Joint Dysfunctions
D7810 or CPT²	Open reduction of dislocation	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission.
D7820 or CPT²	Closed reduction of dislocation	No	Once per DOS.³ Operative report required on claim submission.
D7830 or CPT²	Manipulation under anesthesia	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission.
D7840 or CPT²	Condylectomy	Yes	Only allowable in hospital, office, or ambulatory surgical center POS. No operative report required on claim submission.
D7850 or CPT²	Surgical discectomy, with/without implant	Yes	Only allowable in hospital, office, or ambulatory surgical center POS. No operative report required on claim submission.
D7860 or CPT²	Arthrotomy	Yes	Only allowable in hospital, office, or ambulatory surgical center POS. No operative report required on claim submission.
D7871 or CPT²	Non-arthroscopic lysis and lavage	Yes	Allowable only once per side (right and left) per three years.
D7899	Unspecified TMD therapy, by report	Yes	Use this code for billing TMJ assistant surgeon. Procedure must be included in PA request for the surgery itself. Only allowable in hospital or ambulatory surgical center POS.
Repair of Traumatic Wounds
D7910 or CPT²	Suture of recent small wounds up to 5 cm	No	Emergency only¹—operative report required on claim submission. Once per DOS.³
Complicated Suturing (Reconstruction requiring delicate handling of tissues and wide undermining for meticulous closure)
D7911 or CPT²	Complicated suture—up to 5 cm	No	Covered for trauma (emergency) situations only.¹ Once per DOS.³ Operative report required on claim submission.
D7912 or CPT²	Complicated suture—greater than 5 cm	No	Covered for trauma (emergency) situations only.¹ Once per DOS.³ Operative report required on claim submission.
Other Repair Procedures
D7940 or CPT²	Osteoplasty—for orthognathic deformities	Yes	Only allowable in hospital, office, or ambulatory surgical center POS. No operative report required on claim submission. Allowable age less than 21.
D7950 or CPT²	Osseous, osteoperiosteal, or cartilage graft of the mandible or facial bones—autogeneous or nonautogeneous, by report	Yes	Only allowable in hospital, office, or ambulatory surgical center POS. No operative report required on claim submission.
D7951	Sinus augmentation with bone or bone substitutes	No
D7961 or CPT²	Buccal/labial frenectomy (frenulectomy)	No	Covered areas of the oral cavity are 01 and 02. The area of the oral cavity is required to be indicated on the claim. Up to two units of service per area of the oral cavity allowed per DOS. Total of four units per DOS. Note: An image of the obstructed frenum is not required to be submitted with claims but must be available in the medical or dental record. A dentist statement regarding the medical/dental need for the treatment is required to be available upon request. Refer to the Frenulectomy Procedures Online Handbook topic for limitations and requirements.
D7962 or CPT²	Lingual frenectomy (frenulectomy)	No	Covered areas of the oral cavity are 01 and 02. The area of the oral cavity is required to be indicated on the claim. Up to two units of service per area of the oral cavity allowed per DOS. Total of four units per DOS. Note: An image of the obstructed frenum is not required to be submitted with claims but must be available in the medical or dental record. A dentist statement regarding the medical/dental need for the treatment is required to be available upon request. Refer to the Frenulectomy Procedures Online Handbook topic for limitations and requirements.
D7970 or CPT²	Excision of hyperplastic tissue per arch	Yes	No operative report required on claim submission.
D7972 or CPT²	Surgical reduction of fibrous tuberosity	No	Operative report required on claim submission.
D7979	Non-surgical sialolithotomy	No	No operative report required on claim submission.
D7980 or CPT²	Surgical sialolithotomy	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required on claim submission.
D7991 or CPT²	Coronoidectomy	Yes	Only allowable in hospital or ambulatory surgical center POS. No operative report required on claim submission.
D7997 or CPT²	Appliance removal (not by dentist who placed appliance), includes removal of archbar	No	Operative report required on claim submission.
D7999 or CPT²	Unspecified oral surgery procedure, by report	Yes	For medically necessary unspecified oral surgery procedure, by report. Use this code only if a service is provided that is not accurately described by other HCPCS or CPT procedure codes. Note: For occlusal guard use procedure code D9440.

¹ Retain records in member files regarding nature of emergency.
² Providers who are enrolled in Wisconsin Medicaid as oral surgeons or oral pathologists and who choose CPT billing must use a CPT code to bill for this procedure. Refer to the Dental Maximum Allowable Fee Schedule for allowable CPT procedure codes.
³ Frequency limitation may be exceeded if a narrative on the claim demonstrates medical necessity for additional services.

D8000–D8999 Orthodontics

Covered orthodontic services are identified by the allowable CDT procedure codes listed in the following table. Medicaid reimbursement is allowable only for services that meet all program requirements. This includes documenting the medical necessity of services in the member's medical record.

Code	Description of Service	Prior Authorization?	Limitations and Requirements
Limited Orthodontic Treatment
D8010	Limited orthodontic treatment of the primary dentition	Yes	Allowable age less than 21.
D8020	Limited orthodontic treatment of the transitional dentition	Yes	Allowable age less than 21.
D8030	Limited orthodontic treatment of the adolescent dentition	Yes	Allowable age less than 21.
D8040	Limited orthodontic treatment of the adult dentition	Yes	Allowable age less than 21.
Interceptive Orthodontic Treatment
D8050	Interceptive orthodontic treatment of the primary dentition	Yes	Allowable age less than 21.
D8060	Interceptive orthodontic treatment of the transitional dentition	Yes	Allowable age less than 21.
Comprehensive Orthodontic Treatment
D8070	Comprehensive orthodontic treatment of the transitional dentition	Yes	Allowable age less than 21.
D8080	Comprehensive orthodontic treatment of the adolescent dentition	Yes	Allowable age less than 21.
D8090	Comprehensive orthodontic treatment of the adult dentition	Yes	Allowable age less than 21.
Minor Treatment to Control Harmful Habits
D8210	Removable appliance therapy	Yes	Allowable age less than 21.
D8220	Fixed appliance therapy	Yes	Allowable age less than 21.
Other Orthodontic Services
D8660	Pre-orthodontic treatment visit	No	Allowable age less than 21. Includes exam, diagnostic tests and consult.
D8670	Periodic orthodontic treatment visit (as part of contract)	No for initial 24 units requested Yes for 25^th unit or more	Allowable age less than 21. Used for monthly adjustments.
D8680	Orthodontic retention (removal of appliances, construction and placement of retainer[s])	Yes	Allowable age less than 21.
D8695	Removal of fixed orthodontic appliances for reasons other than completion of treatment	Yes	Covered for members ages 0 to 20 years. Allowable once per member per provider. Coverage is considered on a case-by-case basis with a review of the following requirements: Supporting documentation explaining the rationale for terminating existing treatment, including, but not limited to, clinical or member considerations. A signed statement showing the member's, and/or member's authorized representative, approval of the service.
D8698	Re-cement or re-bond fixed retainer—maxillary	No
D8699	Re-cement or re-bond fixed retainer—mandibular	No
D8703	Replacement of lost or broken retainer—maxillary	No	Covered for members ages 0 to 20 years.
D8704	Replacement of lost or broken retainer—mandibular	No	Covered for members ages 0 to 20 years.

Topic #2807

Dental Hygienist Allowable Services

Dental hygienists may be reimbursed for the following procedures only:

D0191 (Assessment of a patient)
D0701 (Panoramic radiographic image—image capture only)
D0702 (2-D cephalometric radiographic image—image capture only)
D0703 (2-D oral/facial photographic image obtained intra orally or extra orally—image capture only)
D0705 (Extra-oral posterior dental radiographic image—image capture only)
D0706 (Intraoral—occlusal radiographic image—image capture only)
D0707 (Intraoral—periapical radiographic image—image capture only)
D0708 (Intraoral—bitewing radiographic image—image capture only)
D0709 (Intraoral—complete series of radiographic images—image capture only)
D1110 (Prophylaxis—adult)
D1120 (Prophylaxis—child)
D1206 (Topical application of fluoride varnish)
D1208 (Topical application of fluoride)
D1351 (Sealant—per tooth)
D1354 (Interim caries arresting medicament application—per tooth)
D4341 (Periodontal scaling and root planing—four or more teeth per quadrant)
D4342 (Periodontal scaling and root planing—one to three teeth per quadrant)
D4346 (Scaling in presence of generalized moderate or severe gingival inflammation—full mouth, after oral evaluation)
D4355 (Full mouth debridement to enable comprehensive evaluation and diagnosis)
D4910 (Periodontal maintenance)

Providers are required to obtain PA for certain specified services before delivery of that service. The procedure codes that always require PA are D4341, D4342, D4346, and D4910. Procedure code D4355 requires PA when performed on children through the age of 12.

Additional information for dental hygienists regarding other dental service categories and related coverage limitations is available:

Topic #2824

Diagnosis Codes

Current Dental Terminology Codes

Dentists are not required to indicate a diagnosis code on ADA 2012 Claim Forms, 837D transactions, or on PA requests with CDT procedure codes.

Other Procedure Codes

Diagnosis codes indicated on 1500 Health Insurance Claim Forms and 837P transactions (and PA requests when applicable) must be from the ICD coding structure. Etiology and manifestation codes may not be used as a primary diagnosis.

Providers are responsible for keeping current with diagnosis code changes. Those 1500 Health Insurance Claim Forms and 837P transactions (and PA requests when applicable) received with a CPT code but without an allowable ICD diagnosis code are denied.

Topic #2816

Modifiers

Oral surgeons and oral pathologists submitting 1500 Health Insurance Claim forms and 837P transactions with CPT codes for oral surgeries are to use modifier "80" (Assistant surgeon) on claims to designate when a provider assists at surgery.

Topic #2814

Information is available for DOS before October 1, 2023.

Place of Service Codes

The following table lists the allowable POS codes for dental services.

POS Code	Description
03	School
05	Indian Health Service Free-Standing Facility
06	Indian Health Service Provider-Based Facility
07	Tribal 638 Free-Standing Facility
08	Tribal 638 Provider-Based Facility
11	Office
12	Home
15	Mobile Unit
19	Off Campus—Outpatient Hospital
21	Inpatient Hospital
22	On Campus—Outpatient Hospital
23	Emergency Room—Hospital
24	Ambulatory Surgical Center
27	Outreach Site/Street
31	Skilled Nursing Facility
32	Nursing Facility
50	Federally Qualified Health Center
51	Inpatient Psychiatric Facility
71	Public Health Clinic
72	Rural Health Clinic

Providers should refer to the maximum allowable fee schedule for the most up-to-date POS information. Providers are reminded that the POS code must accurately represent the location where the service was rendered.

Topic #2449

Information is available for DOS before October 1, 2023.

Place of Service Codes for Oral Surgeons

Allowable POS codes for oral surgery services are listed in the following table.

POS Code	Description
05	Indian Health Service Free-Standing Facility
06	Indian Health Service Provider-Based Facility
07	Tribal 638 Free-Standing Facility
11	Office
12	Home
15	Mobile Unit
19	Off Campus—Outpatient Hospital
20	Urgent Care Facility
21	Inpatient Hospital
22	On Campus—Outpatient Hospital
23	Emergency Room—Hospital
24	Ambulatory Surgical Center
27	Outreach Site/Street
31	Skilled Nursing Facility
32	Nursing Facility
33	Custodial Care Facility
34	Hospice
50	Federally Qualified Health Center
51	Inpatient Psychiatric Facility
54	Intermediate Care Facility/Individuals with Intellectual Disabilities
61	Comprehensive Inpatient Rehabilitation Facility
71	Public Health Clinic
72	Rural Health Clinic

Topic #2820

Tooth Numbers and Letters

BadgerCare Plus recognizes tooth letters "A" through "T" for primary teeth and tooth numbers "1" through "32" for permanent teeth.

BadgerCare Plus also recognizes supernumerary teeth that cannot be classified under "A" through "T" or "1" through "32." For primary teeth, an "S" will be placed after the applicable tooth letter (values "AS" through "TS"). For permanent teeth, enter the sum of the value of the tooth number closest to the supernumerary tooth and 50. For example, if the tooth number closest to the supernumerary tooth has a value of 12, the provider will indicate supernumerary with the number 62 (12 + 50 = 62).

Topic #2866

Tooth Surfaces

BadgerCare Plus has identified BadgerCare Plus allowable tooth surface codes for dental services providers.

Anterior Teeth (Centrals, Laterals, Cuspids)

Surface	Code
Mesial	M
Facial	F
Incisal	I
Lingual	L
Distal	D
Gingival	G

Posterior Teeth (Pre-molars/Bicuspids, Molars)

Surface	Code
Mesial	M
Bucal	B
Occlusal	O
Lingual	L
Distal	D
Gingival	G

BadgerCare Plus reimburses only per unique surface regardless of location. When gingival (G) is listed with a second surface, such as BG, BFG, DG, FG, LG, MG, the combination is considered a single surface. Also, "FB" is considered one surface since the two letters describe the same tooth surface.

Topic #643

Unlisted Procedure Codes

According to the HCPCS codebook, if a service is provided that is not accurately described by other HCPCS CPT procedure codes, the service should be reported using an unlisted procedure code.

Before considering using an unlisted, or NOC, procedure code, a provider should determine if there is another more specific code that could be indicated to describe the procedure or service being performed/provided. If there is no more specific code available, the provider is required to submit the appropriate documentation, which could include a PA request, to justify use of the unlisted procedure code and to describe the procedure or service rendered. Submitting the proper documentation, which could include a PA request, may result in more timely claims processing.

Unlisted procedure codes should not be used to request adjusted reimbursement for a procedure for which there is a more specific code available.

Unlisted Codes That Do Not Require Prior Authorization or Additional Supporting Documentation

For a limited group of unlisted procedure codes, ForwardHealth has established specific policies for their use and associated reimbursement. These codes do not require PA or additional documentation to be submitted with the claim. Providers should refer to their service-specific area of the Online Handbook on the ForwardHealth Portal for details about these unlisted codes.

For most unlisted codes, ForwardHealth requires additional documentation.

Unlisted Codes That Require Prior Authorization

Certain unlisted procedure codes require PA. Providers should follow their service-specific PA instructions and documentation requirements for requesting PA. For a list of procedure codes for which ForwardHealth requires PA, refer to the service-specific interactive maximum allowable fee schedule.

In addition to a properly completed PA request, documentation submitted on the service-specific PA attachment or as additional supporting documentation with the PA request should provide the following information:

Specifically identify or describe the name of the procedure/service being performed or billed under the unlisted code.
List/justify why other codes are not appropriate.
Include only relevant documentation.
Include all required clinical/supporting documentation.

For most situations, once the provider has an approved PA request for the unlisted procedure code, there is no need to submit additional documentation along with the claim.

Unlisted Codes That Do Not Require Prior Authorization

If an unlisted procedure code does not require PA, documentation submitted with the claim to justify use of the unlisted code and to describe the procedure/service rendered must be sufficient to allow ForwardHealth to determine the nature and scope of the procedure and to determine whether or not the procedure is covered and was medically necessary, as defined in Wisconsin Administrative Code.

The documentation submitted should provide the following information related to the unlisted code:

Specifically identify or describe the name of the procedure/service being performed or billed under the unlisted code.
List/justify why other codes are not appropriate.
Include only relevant documentation.

How to Submit Claims and Related Documentation

Claims including an unlisted procedure code and supporting documentation may be submitted to ForwardHealth in the following ways:

If submitting on paper using the 1500 Health Insurance Claim Form, the provider may do either of the following:
- Include supporting information/description in Item Number 19 of the claim form.
- Include supporting documentation on a separate paper attachment. This option should be used if Item Number 19 on the 1500 Health Insurance Claim Form does not allow enough space for the description or when billing multiple unlisted procedure codes. Providers should indicate "See Attachment" in Item Number 19 of the claim form and send the supporting documentation along with the claim form.
If submitting electronically using DDE on the Portal, PES software, or 837 electronic transactions, the provider may do one of the following:
- Include supporting documentation in the Notes field. The Notes field is limited to 80 characters.
- Indicate that supporting documentation will be submitted separately on paper. This option should be used if the Notes field does not allow enough space for the description or when billing multiple unlisted procedure codes. Providers should indicate "See Attachment" in the Notes field of the electronic transaction and submit the supporting documentation on paper.
- Upload claim attachments via the secure Provider area of the Portal.

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