Program Name: | BadgerCare Plus and Medicaid | Handbook Area: | Dental | 05/10/2024 | Covered and Noncovered Services : CodesTopic #2808 BadgerCare Plus/Medicaid Diagnostic, Preventive, Restorative, Endodontics, Periodontics, General Codes
The following procedure codes are reimbursed under BadgerCare Plus and Medicaid.
D0100D0999 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 |
2D cephalometric radiographic image image capture only |
No |
Orthodontia or oral surgery diagnosis only. |
D0703 |
2D 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 1320. |
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.
D1000D1999 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 1320. 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 020 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 020 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. |
D2000D2999 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 AT and ASTS only). Permanent
teeth: Once per tooth, per three years, per provider1 (tooth numbers 132
and 5182 only). |
D2150 |
Amalgam two surfaces, primary or
permanent |
No |
Primary teeth: Once per
tooth, per year, per member, per provider1 (tooth letters AT and ASTS only). Permanent
teeth: Once per tooth, per three years, per member, per provider1 (tooth numbers 132
and 5182 only). |
D2160 |
Amalgam three surfaces, primary or
permanent |
No |
Primary teeth: Once per
tooth, per year, per provider1 (tooth letters AT and ASTS only). Permanent
teeth: Once per tooth, per three years, per member, per provider1 (tooth numbers 132
and 5182 only). |
D2161 |
Amalgam four or more surfaces,
primary or permanent |
No |
Primary teeth: Once per
tooth, per year, per member, per provider1 (tooth letters AT and ASTS only). Permanent
teeth: Once per tooth, per three years, per member, per provider1 (tooth numbers 132
and 5182 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
611, 2227, CH, MR, 5661, 7277, CSHS, and MSRS 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 611, 2227,
CH, MR, 5661, 7277, CSHS, and MSRS 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
611, 2227, CH, MR, 5661, 7277, CSHS, and MSRS 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 611, 2227,
CH, MR, 5661, 7277, CSHS, and MSRS 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 DG, DSGS only). Permanent teeth: Once per
five years, per tooth (tooth numbers 611, 2227, 5661, 7277 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 15, 1221, 2832, 5155, 6271, and
7882 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 15, 1221, 2832, 5155, 6271, and
7882 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 15, 1221, 2832, 5155, 6271, and
7882 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 15, 1221, 2832, 5155, 6271, and
7882 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 132, AT,
5182, and ASTS.) 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 132, 5182
only. |
D2915 |
Re-cement or re-bond indirectly fabricated or
prefabricated post and core |
No |
Tooth numbers 132, AT, 5182, ASTS. |
D2920 |
Re-cement or re-bond crown |
No |
Tooth numbers 132, AT, 5182, ASTS. |
D2928 |
Prefabricated porcelain/ceramic crown permanent tooth |
No |
Once per five years, per tooth (tooth numbers 132 and 5182 only). |
D2929 |
Prefabricated porcelain/ceramic crown primary tooth |
No |
Once per year, per tooth (tooth letters AT and ASTS only).2 |
D2930 |
Prefabricated stainless steel crown primary tooth |
No |
Once per year, per tooth (tooth letters AT and ASTS only).2
|
D2931 |
Prefabricated stainless steel crown permanent tooth |
No |
Once per five years, per tooth (tooth numbers 132 and 5182 only). |
D2932 |
Prefabricated resin crown |
No |
Primary teeth: Once per
year, per tooth (tooth letters DG and DSGS only). Permanent teeth: Once per five years, per tooth (tooth numbers 611, 2227, 5661, and 7277 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 DG, DSGS only). Permanent teeth: Once per
five years, per tooth (tooth numbers 611 and 5661 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 DG and DSGS only. |
D2940 |
Protective restoration |
No |
Not allowed with pulpotomies, permanent restorations, or endodontic procedures (tooth numbers 132, AT, 5182, and ASTS). |
D2951 |
Pin retention per tooth,
in addition to restoration |
No |
Once per three years, per
tooth (tooth numbers 132 and 5182 only).1
|
D2952 |
Post and core in
addition to crown, indirectly fabricated |
No |
Once per tooth, per
lifetime, per member, per provider. Tooth numbers 215, 1831, 5265, and 6881 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 215, 1831, 5265, and 6881 only.
Cannot be billed with D2952. |
D2971 |
Additional procedures to
customize a crown to fit under an existing partial denture framework |
No |
Tooth numbers 215 and
1831 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.
D3000D3999 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 AT and ASTS
only). |
D3221 |
Pulpal debridement, primary and permanent teeth |
No |
Allowable for tooth numbers 215, 1831, 5265, and 6881 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 215, 1831, 5265, and 6881 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 25, 1215, 1821, 2831, 5255, 6265,
6871, and 7881 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 215, 1831 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 215, 1831 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 215, 1831 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 611, 2227, 5661, and 7277
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 611, 2227, 5661, and 7277
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. |
D9000D9999 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 020), 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 020), 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 020) 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 020), 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 020), 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 020), 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 132, AT,
5182, and ASTS. 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. |