For Dates of Service Before January 1, 2017

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 No One per six-month period, per provider, for members under the age of 21.
D0140 Limited oral evaluation — problem focused No One per six months, per provider.
D0150 Comprehensive oral evaluation — new or established patient No One per three years, per provider.
D0160 Detailed and extensive oral evaluation — problem focused, by report No One per three years, per provider.
D0170 Re-evaluation limited, problem focused (established patient; not post-operative visit) No Allowed once per year, per provider.
Allowable in office or hospital POS.
D0191 Assessment of a patient No One per six months, per provider. Code billable only by dental hygienists.
Radiographs/Diagnostic Imaging (Including Interpretation)
D0210 Intraoral — complete series (radiographic image) No3 One per three years, 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 periapical — first radiographic image No One per day.
Not payable with D0210 on same DOS or up to six months after.2
D0230 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 occlusal radiographic image No Up to two per day.
Not payable with D0210 on same DOS.
D0250 Extraoral — first radiographic image No Emergency only, one per day.1
D0260 each additional radiographic image No Emergency only, only two per day.1
Must be billed with D0250.
D0270 Bitewing(s) — single radiographic image No One per day, up to two per six-month period, per provider.
Not payable with D0210, D0270, D0272, D0273, or D0274 on same DOS or up to six months after.2
D0272 two radiographic images No One set of bitewings per six-month period, per provider.
Not payable with D0210, D0270, D0272, D0273, or D0274 on same DOS or up to six months after.2
D0273 three radiographic images No One set of bitewings per six-month period, per provider.
Not payable with D0210, D0270, D0272, D0273, or D0274 on same DOS or up to six months after.2
D0274 four radiographic images No One set of bitewings per six-month period, 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 Cephalometric radiographic image No Orthodontia diagnosis only.
Allowable for members up to age 20.
D0350 Oral/facial photographic images 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 Service." 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 provider, for ages 21 and older.
One per six-month period, 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 provider, for permanently disabled member.
Retain documentation of disability that impairs ability to maintain oral hygiene.
Allowable for Medicaid-enrolled dental hygienists.
D1120 child No One per six-month period, per provider.
Allowable for members up to age 12.
Special Circumstances: Up to four per 12-month period, 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 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 No Retain documentation regarding medical necessity of sealants placed on teeth other than permanent molars (1, 4-13, 16, 17, 20-29, 32, 51-82, A-T, AS-TS).
Allowable for members up to age 20.
Narrative required in order to exceed once per three-year limitation.
Allowable for Medicaid-enrolled dental hygienists.
Space Maintenance (Passive Applicances)
D1510 Space maintainer — fixed unilateral 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.
D1515 fixed bilateral No Once per year, per arch.
Narrative required to exceed frequency limitation.
Allowable for members up to age 20.
Applicable area of the oral cavity (either 01 [maxillary] or 02 [mandibular]) required on claim form.
D1550 Recementation of space maintainer No Limited to two per DOS.
Allowable for members up to age 20.
D1555 Removal of fixed space maintainer No

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 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 two 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 provider1 (tooth numbers 1-32 and 51-82 only).
D2160 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 provider1 (tooth numbers 1-32 and 51-82 only).
D2161 four or more 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 provider1 (tooth numbers 1-32 and 51-82 only).
Resin-Based Composite Restorations — Direct
D2330 Resin — one surface, anterior No Primary teeth: Once per tooth, per year, per provider.1
Permanent teeth: Once per tooth, per three years, 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 two surfaces, anterior No Primary teeth: Once per tooth, per year, per provider.1
Permanent teeth: Once per tooth, per three years, 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 three surfaces, anterior No Primary teeth: Once per tooth, per year, per provider.1
Permanent teeth: Once per tooth, per three years, 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 four or more surfaces or involving incisal angle (anterior) No Primary teeth: Once per tooth, per year, per provider.1
Permanent teeth: Once per tooth, per three years, 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 children1, and with PA for adults greater than age 20.2
D2391 Resin-based composite — one surface, posterior No Primary teeth: Once per year, 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 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 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 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 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 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 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 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 Recement inlay, onlay or partial coverage restoration No Tooth numbers 1-32, 51-82 only.
D2915 Recement cast or prefabricated post and core No Tooth numbers 1-32, A-T, 51-82, AS-TS.
D2920 Recement 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 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 children1, 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 children1, 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 age less than 21.
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 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 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 Service." Use this code for single-unit crown.
Allowable for members ages 0-20.

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 require PA.
D3320 bicuspid tooth (excluding final restoration) No (see limitations) Normally for permanent bicuspid teeth.
May be used to bill two canals on a bicuspid 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 require PA.
D3330 molar (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 require PA.
Apexification/Recalcification Procedures
D3351 Apexification/recalcification/pulpal regeneration — initial visit (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) No Permanent teeth only (tooth numbers 2-15, 18-31, 52-65, 68-81 only).
Not allowable with root canal therapy.
Bill the entire procedure under this code.
Allowable for members ages less than 21.
Apicoectomy/Periradicular Services
D3410 Apicoectomy/periradicular surgery — 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.

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 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, which makes travel to the dentist difficult, for up to four quadrants per DOS.
Not payable with prophylaxis or a fluoride treatment.
D4342 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, which makes travel to the dentist difficult, for up to four quadrants per DOS.
Not payable with prophylaxis or a fluoride treatment.
D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis No (see limitations) Full mouth code.
Excess calculus must be evident on an X-ray.
One per three years, 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.
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 Service." 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 procedures 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
D9223 Deep sedation/general anesthesia — each 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 D9223 for general anesthesia.
Not payable with D9230, D9243, or D9248.
D9230 Inhalation of nitrous oxide/analgesia, anxiolysis No Allowable for children (ages 0-20), when performed by an oral surgeon or pediatric dentist.
Not payable with D9223, D9243, or D9248.
D9243 Intravenous moderate [conscious] sedation/analgesia — each 15 minute increment Yes (see limitations)
  • 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 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.
    Service must be performed by a Medicaid-enrolled dentist.
    D9420 Hospital call 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
    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.
    D9999 Unspecified adjunctive procedure, by report Yes HealthCheck "Other Service." Use this code for unspecified non-surgical procedures with a HealthCheck referral.

    1Retain records in member files regarding nature of emergency.