For Dates of Service On Before January 1, 2021

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.

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, for members under the age of 21.
D0140 Limited oral evaluation — problem focused No One per six months, per member, per provider.
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.
D0191 Assessment of a patient No One per six months, per member, per provider. Code billable only by dental hygienists.
Radiographs/Diagnostic Imaging (Including Interpretation)
D0210 Intraoral — complete series of radiographic images 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, and detector No Emergency only, one per day.1
D0270 Bitewing — single radiographic image No One per day, up to two per six-month period, per member, per provider.
Not payable with D0210, D0270, 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, D0272, 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, D0273, 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, D0273, or D0274 on same DOS or up to six months after.2
D0277 Vertical bitewings — 7 to 8 radiographic images No Only for adults ages 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.
Tests and Examinations
D0470 Diagnostic casts No Orthodontia diagnosis only.
Allowed with PA for members ages 21 and over, at BadgerCare Plus's request (e.g., 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 Interim 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.
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 construct new crown under 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 on four or more teeth requires 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 on four or more teeth requires 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 on four or more teeth requires 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:
  1. For hospital or ASC POS.
  2. In an emergency.1
  3. 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:
  1. For hospital or ASC POS.
  2. In an emergency.1
  3. 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:
  1. For hospital or ASC POS.
  2. In an emergency.1
  3. 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:
  1. For hospital or ASC POS.
  2. In an emergency.1
  3. 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 — single or multiple sites 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.
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.